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Body Image questionnaire

Body image Questionnaire

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.

In answering the questions below, these are the ‘features’ we ask you to reflect upon
1. How satisfied or dissatisfied are you with the feature/s that are the focus of the consultation?*

Very SatisfiedSlightly SatisfiedModerately DissatisfiedVery Dissatisfied

2. 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.

Never check5 times / day10 times / day20 times / day40 times / day

3. To what extent do you feel these feature/s are currently “ugly”?*

Not at all uglySlightly uglyModerately uglyMarkedly uglyVery ugly

4. To what extent do these feature/s currently cause you distress?*

Not at allSlightly distressingModerately distressingMarkedly distressingSeverly distressing

5. 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.

Not at allSlightly preoccupiedModerately preoccupiedVery preoccupiedExtremely preoccupied

6. 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?

Not at allSlightlyModeratelyMarkedlyExtremely

7. 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?*

Not at allSlightlyModeratelyMarkedlyVery seriously

8. To what extent do these feature/s interfere with your social life?*

Not at allSlightlyModeratelyMarkedlySeverely

9. To what extent, do you feel your appearance is the most important aspect of who you are?*

Not at allSlightlyModeratelyMarkedlyTotally

10. How important is your overall appearance to the way you feel about yourself/your sense of self-worth?*

Not at allModerately importantExtremely important

11. Do you worry (feel concerned or anxious) about the impressions people are forming when they are looking at you?*

Not at allyes, very anxious

12. Have you had any aesthetic surgery/cosmetic procedures in the past?*
If ‘yes’, were you happy or unhappy with the results?
13. Has any other cosmetic surgeon or cosmetic practitioner declined to offer you treatment?*
14. 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?*
15. All procedures carry risks. Have you considered how you might feel if you experience a complication, slow recovery, delayed healing or require revision surgery?*

Thank 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.


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).