Aesthetic Specialist Patient Interest Questionnaire

Which areas would you like to improve? (check all that apply)

Forehead linesFrown linesCrow's feet linesSkin texture and appearanceFlattened / sunken cheeksLines & wrinkles around the nose and mouthThin lipsLip appearance and textureSmall / weak chin profile

How do you feel about your appearance? (check all that apply)

I look tiredI look sadI look angryI have saggy skinI look older than my ageI don't look contouredI don't look smoothI don't look aesthetically pleasing

Anything else you'd like us to know?

Preferred day of the week?

MondayTuesdayWednesdayThursdayFriday

Preferred time of day?

MorningAfternoon