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EDUCATION:
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Number of years in Elementary
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Number of years in High School
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Number of years in College
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With OCCUPATION?
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OCCUPATION:
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HOW LONG?
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Type/s of surgery you're considering:
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OTHER
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What specific features do you dislike?
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How long have you been thinking about having surgery?
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What caused you to begin thinking about having it?
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Have you read articles in newspapers, magazines, or books about cosmetic surgery?
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Do you understand that the object of any cosmetic operation is improvement in appearance, not perfection?
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Has anyone in your family or a friend had cosmetic surgery?
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What was done?
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Did you discuss the operation with them?
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Why did you wait until now to come in for correction?
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How did you happen to select us for consultation?
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Have you consulted any other surgeon?
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Why didn't you have him do the work?
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Is having surgery your idea or is someone else urging you to have it?
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Do you feel embarrassed about wanting the operation?
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If you have the operation, who do you think will be the happiest with the results?
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Reason/s why you want the operation: (select all that apply)
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Others:
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What do you expect the operation to do for you: (select all that apply)
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Others:
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Do you have any preconceived idea of how you'd like your nose, face, etc., to look?
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How?
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I realize that every operation is followed by a period of healing before the tissues return to normal & final result is apparent
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Have you had any previous cosmetic operations?
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List any previous cosmetic operations you have had:
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Were you satisfied with the results?
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Were you satisfied with the doctor/s?
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If not, why not?
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Civil Status
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(If applicable) When were you married, separated, divorced or widowed?
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Do you live with someone else (family, friends)?
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Have you spoken to them of your desire for surgery?
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