PATIENT SURVEY
Demographics:
Age:
Gender: M/F
Marital Status: Married/Single/Divorced
Children: Y/N
Smoking history: Y/N
Amount of lifetime exposure to sun (choose one):
Minimal (never had blistering burn, cover up in sun, wear sunscreen daily)
Intermediate
Heavy (numerous blistering burns, sun bathe regularly, rarely wear sunscreen, history of skin cancer)
Highest Educational Level: Elementary/High School/College/Master’s/Doctorate
Employment Status: Y/N
Annual Family Income: <$25,000/$25-50,000/$50-$75,000/$75-150,000/>$150,000
History of prior facial cosmetic procedures (i.e. facelift, eyelid lift, browlift): Y/N
Have you recently (within the last year) had a major change in your professional or personal life?:
Y/N, if yes,
marriage/divorce/death of loved one/recovery from illness/other________
Have you ever sought out treatment with a psychiatrist or a therapist?: Y/N
General
What facial feature are you wishing to improve?:
Eyes or Around the Eyes /
Cheeks / Lips
/
Nose / Neck
What facial feature do you feel has aged the most/first?:
Eyes or Around the Eyes / Cheeks / Lips / Nose / Neck
What other steps have you taken to improve the appearance of your face?:
sunscreen/ OTC cosmeceuticals/chemical peels/topical retinoids/lasers/other_____
Have you had recent treatments with a medical esthetician? Y/N
Have you had recent facial treatments at a spa? Y/N
Do you use sunscreen regularly?: Y/N
How important do you think skin care is to improving the appearance of aging in the face?:
1(not important)…..10(very important)
Are you or would you in the future consider facial surgery?: Y/N
How do you think this treatment will affect your appearance?:
Minimally/Moderately/Significantly
Do you know from which treatment you would benefit most?:
Chemical denervation with Botulinum
augmentation/Other___________
toxin/Dermal
filler
replacement/Soft
How did you hear about these treatments?:
Friends/Family/Paper/Online/TV/Colleague/Other_______
Do you know anyone who has personally undergone these treatments?: Y/N
What/who influenced you the most in pursuing these treatments? (select all that apply):
Spouse or Significant Other
Child
Friend
Media/Hollywood
Upcoming important social event
Desire or pressure to look good or young in the work setting
Recent significant weight loss
Recent life-changing event/desire to “look how you feel”
Being teased by others
Other___________________________
Do you plan to undergo these treatments on a repeated basis?: Y/N/Undecided
tissue
If you have considered these treatments for greater than 6 months, what has deterred you from seeking out
treatment until now? (select all that apply):
Financial restraint
Stigma of procedures
Concern from loved ones
Uninformed about procedure
Upcoming important social event
Desire or pressure to look good or young in the work setting
Other_________________________
How much of an influence has the Internet played in your choice of seeking out treatment?:
1(not important)…..10(very important)
What was the major influence in your selection of the treating physician? (select all that apply):
Reputation
Referral from friend or loved one
Referral from another physician
Trust in institution
Marketing by physician or department
Other____________________________
Who performs more of these treatments: Plastic Surgeon/Dermatologist/Other________
Is one specialty better trained than the other to carry out these procedures?:
Y/N, If yes, explain:______________________
Is there more pressure from the media/public to maintain one’s youthful appearance now than in the past?:
Y/N
At the 6 and 12 week follow-up for enrolled participants, what is your level of satisfaction after treatment?
1(extremely dissatisfied)……5(extremely satisfied)
Medical Knowledge:
What are the possible complications of a neuromodulator (e.g. Botox)?:
Which one are you most concerned about?:
How often do you anticipate needed repeated treatments?:
weekly/monthly/quarterly/annually/bi-annually
What are the possible complications of a dermal or soft tissue filler?:
Which one are you most concerned about?
How often do you anticipate needed repeated treatments?:
weekly/monthly/quarterly/annually/bi-annually
Is your goal to prevent or delay facial rejuvenation surgery?: Y/N
Follow-up Questions for Treatment Patients (weeks 6 and 12)
Was your last vist what you expected?: Y/N
If no, please explain:`
What treatment did you receive?: _______________________
Are you satisfied with the outcome with the treatment?: Y/N
If no, please explain:
Would you choose to repeat the treatment? Y/N
If no, please explain: