Personal Preference Form: Facial Rejuvenation 
Name:
Telephone:
Date of Appointment:

PART A. SURGICAL QUESTIONS
1. What best describes your interest?
Purely appearance
Mainly appearance with some breathing correction required
Appearance and breathing of about equal concern
Mainly improvement of breathing with a small refinement of look
Purely breathing
2. What do you want corrected?
Please list by number your priority for each option
The shape of the bridge on profile, hump
Drooping of the tip, especially when I smile
Crooked to one side (when seen front on)
Irregularities of the bridge (from front on)
Too broad (thick) across the bridge
Tip looks too rounded, like a ball
Tip too broad
Too much nostril showing from the side
I wish to raise the bridge because I have an Oriental nose
Other
3. My knowledge, concerns and fears about rhinoplasty.
I am concerned about what I have heard about packs Yes  No
I am concerned about pain after surgery Yes  No
I am worried about the anaesthetic Yes  No
I am worried about how I will look Yes  No
I am worried about the time I need to be off work Yes  No
I do not want people to know I have had my nose done. I am worried the surgery may be too obvious Yes  No
I am worried that I may be disappointed because the improvement will be too subtle Yes  No
4. Previous nasal history.
(1) Do you suffer allergies affecting the nose?

(a) Hayfever
(b) Asthma

Yes  No
Yes  No
(2) Have you had any previous surgery on your nose? Yes  No
(3) If yes, was this for

(a) breathing
(b) appearance
(c) both

Yes  No
Yes  No
Yes  No
(4) Have you broken your nose as a child (pre-teen)? Yes  No
(5) Have you broken your nose when older (ie with major bleeding/bruising)? Yes  No
 
PART B. OTHER CONSIDERATIONS REGARDING YOUR SURGERY
Have you wanted to have this surgery for a long time, or is it a recent desire?
Are you undergoing any other significant changes in your life at this time?
Are you prepared for people to notice, or comment, on your changed nose shape?
Has anyone else in your family had plastic surgery and how did this influence you?
Has some particular life event triggered your decision eg break-up of a relationship
Do you have a particular goal which this surgery forms part of?
Are you consciously looking to change your life?
Are you looking forward to having this surgery?
Was this a difficult decision, or an easy one?
Please attach two or more current photos of yourself, in profile and full face (.gif or .jpeg extension image files only):

Photo 1:
Photo 2:
Photo 3:
Photo 4:
 
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