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Cosmetic Surgery Evaluation Questionnaire
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Please select below the types of surgery you are considering:
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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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Did you discuss the operation with them?
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Have you consulted any other surgeon?
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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 guilty or 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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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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Check below the reasons why you want the operation:
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Check below what you expect the operation to do for you:
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Do you have a preconceived idea of how you would like your nose, face, etc., to look?
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Do you realize that every operation is followed by a period of healing before the tissues return to normal and the
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List below 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 doctors?
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Are you presently single, married, separated, divorced or widowed?
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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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Do you mind what they think?
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Have you spoken to any of your friends about having surgery?
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Have you recently experienced any significant disappointment, sorrow, or loss of self-esteem?
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Any emotional crisis at home, work, or in your relationship with another person or group?
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Do you:
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Medical Evaluation
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How is your general health?
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Are you under the care of a doctor for anything at the present time?
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If yes, for what?
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If no, should you be, but have been putting off consulting one?
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When was you last physical examination?
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Was everything O.K.?
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Do you seem to be ill more frequently than other people you know?
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Are you having any trouble with your teeth or gums?
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Do you wear partial or complete dentures?
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Do you wear eye glasses or contacts or feel you need them?
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Do you have any other eye complaints?
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Do you have any chronic nose or sinus complaints?
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Do you have frequent headaches?
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Do you have asthma or any chronic lung or bronchial condition?
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Do you experience recurrent chest pains?
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Have you ever been told you have any trouble with your heart?
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Do you have any abdominal problems? (stomach, intestinal, gall
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Any trouble with your kidneys, bladder or reproductive system?
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Any bone, joint or muscular trouble?
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Do you have any chronic skin condition?
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Do you have any of the following?
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Have you ever had a nervous breakdown?
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Have you ever been under the care of a psychiatrist or psychologist?
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Have you ever been dissatisfied with the treatment you received from a doctor or dentist?
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Have you had any marked loss or gain of weight lately?
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Are you on a special diet at the present time?
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Do you bruise easier than most other people?
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Do bruises seem to take longer to clear up for you than for most people you know?
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Do your cuts bleed longer than those other people have?
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Do blood vessels in your skin sometimes break without apparent cause?
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Have you ever had any bleeding episode that required the attention of a doctor?
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For Women
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(For Women): Do your periods usually lasts longer than 4 or 5 days?
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Have you ever had any of the following:
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If you have been operated on previously, did you have any unusual bleeding or poor scarring ff surgery or any injury or vacc?
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Did you have a normal recovery following previous surgery?
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Do you understand that anyone undergoing any operation, even cosmetic one, must assume certain risks?
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Do you understand that no surgeon can guarantee good results in any operation he performs?
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Were you satisfied with the results of the previous surgery you had?
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Have you ever had excessive bleeding more than once during your life?
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Have you ever had hemorrhage following minor surgery?
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Have you suffered with recurrent nosebleeds?
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As far as you know, have you ever had an allergic reaction to any of the following drugs or materials:
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Other:
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Is there any history of any of the following conditions in your family:
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List below any other facts of a medical
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Date
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Signature
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List below any questions you would like to have specifically answered
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