PreFace Assessment Form |

Name*

First Last

In general, would you say your health is:*

Recently, have you felt constantly under strain?*

Recently, have you found everything getting on top of you?*

Recently, have you been losing confidence in yourself?*

Do you still enjoy the things you used to enjoy?*

Have you ever spent a lot of time worrying about a defect in your appearance/bodily functioning?*

Before going out, you usually spend a lot of time getting ready?*

How dissatisfied or satisfied are you with your body area that you are considering surgery for?*

Have you been dissatisfied with the outcome of any previous aesthetic surgical or cosmetic dentistry procedures?*