Body Image questionnaireHome > Body Image QuestionnaireBody image QuestionnaireFirst Name*Last Name*Why am I completing this form?Government regulations require any patient considering a procedure that may involve aesthetic improvement, to complete a body image questionnaire, prior to considering surgery.Please list the feature/s that you wish to consult us about.*In answering the questions below, these are the ‘features’ we ask you to reflect upon1. How satisfied or dissatisfied are you with the feature/s that are the focus of the consultation?* 1 2 3 4 5 6 7 8 9Very SatisfiedSlightly SatisfiedModerately DissatisfiedVery Dissatisfied2. How often do you consciously check these feature/s?*Please include looking at your feature in a mirror (or other reflective surfaces, like a shop window), looking at it directly - or intentionally feeling it with your fingers. 1 2 3 4 5 6 7 8 9Never check5 times / day10 times / day20 times / day40 times / day3. To what extent do you feel these feature/s are currently “ugly”?* 1 2 3 4 5 6 7 8 9Not at all uglySlightly uglyModerately uglyMarkedly uglyVery ugly4. To what extent do these feature/s currently cause you distress?* 1 2 3 4 5 6 7 8 9Not at allSlightly distressingModerately distressingMarkedly distressingSeverly distressing5. To what extent do these feature/s currently preoccupy you?*That is: you think about it a lot and it is hard to stop thinking about it. 1 2 3 4 5 6 7 8 9Not at allSlightly preoccupiedModerately preoccupiedVery preoccupiedExtremely preoccupied6. If you have a partner, to what extent do these feature/s currently influence your relationship?*For example, impact on affectionate feelings, number of arguments, enjoying activities together. If you do not have a partner, to what extent do these your feature/s currently influence dating - or developing a relationship? 1 2 3 4 5 6 7 8 9Not at allSlightlyModeratelyMarkedlyExtremely7. To what extent do these feature/s currently interfere with your ability to work or study or your role at home or with your children?* 1 2 3 4 5 6 7 8 9Not at allSlightlyModeratelyMarkedlyVery seriously8. To what extent do these feature/s interfere with your social life?* 1 2 3 4 5 6 7 8 9Not at allSlightlyModeratelyMarkedlySeverely9. To what extent, do you feel your appearance is the most important aspect of who you are?* 1 2 3 4 5 6 7 8 9Not at allSlightlyModeratelyMarkedlyTotally10. How important is your overall appearance to the way you feel about yourself/your sense of self-worth?* 1 2 3 4 5 6 7 8 9Not at allModerately importantExtremely important11. Do you worry (feel concerned or anxious) about the impressions people are forming when they are looking at you?* 1 2 3 4 5 6 7 8 9Not at allyes, very anxious12. Have you had any aesthetic surgery/cosmetic procedures in the past?* No – please go to question 13 YesIf ‘yes’, were you happy or unhappy with the results? I was happy with the results I was unhappy with the results13. Has any other cosmetic surgeon or cosmetic practitioner declined to offer you treatment?* No – please go to question 14 Yes14. Have you considered the impact that the recovery process may have on your life and work, with limited movement and activities for at least six weeks?* No Yes15. All procedures carry risks. Have you considered how you might feel if you experience a complication, slow recovery, delayed healing or require revision surgery?* No - I have not considered how I might feel Yes - I have given thought to how I might feelThank you for completing this questionnaire. If the result raises concerns about your suitability for surgery, Dr Sharp is required to recommend that you seek further psychological assessment for suitability, prior to proceeding with surgery.If this applies to you, we will be in touch.Sources:Cosmetic Procedure Screening Questionnaire developed by D Veale et al. Journal of Plastic Reconstructive and Aesthetic Surgery, 65 (4), 530-532.PreFACE Questionnaire developed by R Honigman et al. Annals of Plastic Surgery, 65 (12).
