Body Image Form (COSMETIC surgery patients to complete)

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 before 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 upon

    1. How satisfied or dissatisfied are you with the feature/s that are the focus of the consultation?*

    • Very Satisfied

    • Slightly Satisfied

    • Moderately Dissatisfied

    • Very 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 check

    • 5 times / day

    • 10 times / day

    • 20 times / day

    • 40 times / day

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

    • Not at all ugly

    • Slightly ugly

    • Moderately ugly

    • Markedly ugly

    • Very ugly

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

    • Not at all

    • Slightly distressing

    • Moderately distressing

    • Markedly distressing

    • Severely 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 all

    • Slightly preoccupied

    • Moderately preoccupied

    • Very preoccupied

    • Extremely 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 all

    • Slightly

    • Moderately

    • Markedly

    • Extremely

    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 all

    • Slightly

    • Moderately

    • Markedly

    • Very seriously

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

    • Not at all

    • Slightly

    • Moderately

    • Markedly

    • Severely

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

    • Not at all

    • Slightly

    • Moderately

    • Markedly

    • Totally

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

    • Not at all

    • Moderately important

    • Extremely important

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

    • Not at all

    • yes, 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. Foti 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).

    Address

    The Avenue Private Hospital
    42 The Avenue
    Windsor
    Melbourne
    3181

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    Contact Number: (03) 7067 9688
    Fax Number: (03) 7046 6822
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