General Information

Name *

Surname *

DOB *

Email *

Questionnaire

Please read each question carefully and submit the answer that is true for you.

Are you worried about how you look? *

YesNo

Do you think about your appearance problems a lot and wish you could think about them less? *

YesNo

Please list the body areas you don't like: *Examples of disliked body areas include: your skin (for example, acne, scars, wrinkles, paleness, redness); hair; the shape or size of your nose, mouth, jaw, lips, stomach, hips, etc.; or defects of your hands, genitals, breasts, or any other body part.

Is your main concern with how you look that you aren't thin enough or that you might get too fat? *

YesNo

How has this problem with how you look affected your life?

Has it often upset you a lot? *

YesNo

Has it often gotten in the way of doing things with friends, dating, your relationships with people, or your social activities? *

YesNo

If yes: Describe how:

Has it caused you any problems with school, work, or other activities? *

YesNo

If yes: What are these problems?

Are there things you avoid because of how you look? *

YesNo

If yes: What are they?

On an average day, how much time do you usually spend thinking about how you look? (Add up all the time you spend in total in a day) *

Less than 1 hour a day1-3 hours a dayMore than 3 hours a day

Please 'Sign' and click SUBMIT below to complete the questionnaire.

Patient Signature *

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