PreFace Assessment Form Home 5 PreFace Assessment FormPreFace Assessment FormName* First Last In general, would you say your health is:* Excellent Very good Good Fair PoorRecently, have you felt constantly under strain?* Not at all No more than usual Rather more than usual Much more than usualRecently, have you found everything getting on top of you?* Not at all No more than usual Rather more than usual Much more than usualRecently, have you been losing confidence in yourself?* Not at all No more than usual Rather more than usual Much more than usualDo you still enjoy the things you used to enjoy?* Definitely as much Not quite as much Only a little Hardly at allHave you ever spent a lot of time worrying about a defect in your appearance/bodily functioning?* Not at all Same as most people More than most people Much more than most peopleBefore going out, you usually spend a lot of time getting ready?* Definitely disagree Mostly disagree Neither agree nor disagree Mostly agree Definitely agreeHow dissatisfied or satisfied are you with your body area that you are considering surgery for?* Very satisfied Mostly satisfied Neither satisfied or dissatisfied Mostly dissatisfied Very dissatisfiedHave you been dissatisfied with the outcome of any previous aesthetic surgical or cosmetic dentistry procedures?* No, I have not had any previous procedure(s) No, I have been satisfied with previous procedure(s) Yes, I have been dissatisfied with previous procedure(s)
