PATIENT INTEREST QUESTIONNAIRE

ENT OFFICE.ORG.

Please correct the errors described below.

Name:

Age:

Date:

Please indicate any areas of concern for you. Check all that apply

Forehead lines

Frown lines

Crow's feet lines

Thinning or inadequate lashes

Under eye area

Flattened cheeks/sunken cheeks

Lines and wrinkles around the nose and mouth

Thin lips

Lip appearance and texture

Double chin

Small chin/weak chin profile

Skin texture and appearance

Share how you see yourself.

I feel I look tired

I feel I look sad

I feel I look angry

I feel I have saggy skin

I feel I look older than my age

I feel I don't look contoured

I feel I don't look smooth

I feel I don't look aesthetically pleasing

Other

If other, please specify:

For use with your aesthetic provider

Evaluate concerns and aesthetic goals to customize each consultation

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