AESTHETIC QUESTIONNAIRE

Patient name: Date:__________________________________

What is the main reason for your visit today? ________________________________________________________________

_________________________________________________________________________________________________________________________

Have you had a consultation or treatment for a cosmetic procedure before? Yes No

How often do you think about having a cosmetic procedure? most days weekly monthly

I would like to be advised on: o How I can freshen my appearanceo How I can change something that has been bothering me for yearso How I can optimize my looks to get the best version of myselfo How I can look more attractiveo Other_________________________________________________________________________________________________________

Which three statements best reflect how you would like to look after your treatment?

I want to look less tired I want a less saggy appearance I want my face to look more I want to look less angry I want to look more youthful contoured I want to look less sad I want to look more attractive I want to look more masculine

Please circle the area(s) that concern you:

Clinic 805 Cosmetic Surgery & Skincare Centre805 Fairfield Road, Victoria, BC V8V 0A7 P: 250-595-3888 www.clinic805.ca Page 1 of 2

AESTHETIC QUESTIONNAIRE

When looking at my face in the mirror I look younger, the same as, or older than my true age.What features do you: Love ___________________________________________________________________________________________________________ Like ___________________________________________________________________________________________________________ Live with_________________________________________________________________________________________________________Dislike __________________________________________________________________________________________________________

How would you rate the quality of your skin Poor Fair Good Very good Excellent

If you could enhance an aspect of you skin, what would you choose? Hydration Elasticity Smoothness Pigmentation/Redness

These treatments/products interest me: Please circle the treatment(s) of your interest

Skin Enhancement Facial Improvement Body Contouring Other

Skin products Facial fillers Fat reduction Neck liftLaser treatment Wrinkle relaxers Tummy tuck Scar RevisionSkin texture Face liftPeels Nose surgerySkin tightening Eyelid correctionSkin analysis Brow correctionSun damage Ear correction

Fat reduction-chin

I have an important event ____________________________________________________________________________________

How did you hear about us?

Magazine/Print Ad: Search Engine:

Friend/Family Member (please provide name):

Facebook Instagram Other Website:

Dr. Other:

Signature: ___________________________________________________________________________________________________________

Clinic 805 Cosmetic Surgery & Skincare Centre805 Fairfield Road, Victoria, BC V8V 0A7 P: 250-595-3888 www.clinic805.ca Page 2 of 2