Patient Name*:
Name you prefer to be called:
Email*:
Primary Phone:
Age:
Known Allergies:
Known Lidocaine or other topical anesthetic allergy:
What areas would you like us to address?:
Please complete the following:
Do you have concerns about the appearance of some part of your body, which you consider especially unattractive?:
Yes
No
Do these concerns preoccupy you, do you think about them a lot, or are they hard to stop thinking about?:
Yes
No
What are these concerns?:
What specifically bothers you about the appearance of these body parts?:
What effect has your concern had on your life?:
Please evaluate how your concern causes you distress, torment or pain?:
Please evaluate how your concern causes you impairment in social, occupational or other important areas of functioning?:
If your concern often significantly interferes with your social life, please explain how:
Has your concern significantly interfered with you school work, you job, or your ability to function in your role?:
Yes
No
Are there things you avoid because of your concern?:
Yes
No
