Mr/Mrs............................................... | Date............................. |
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Please express yours opinions with a number from 1 to 10, where 1 corresponds to dissatisfied and 10 very satisfied. 1. How much were you satisfied by the aspect of your lips (before surgery)? _____ 2. How much were you satisfied by the skin elasticity of the perioral area (before the intervention)? _____ 3. How much were you satisfied by the aspect of the malar area (before surgery)? _____ 4. How much were you satisfied by the skin elasticity of the malar area (before surgery)? _____ 5. Indicate the discomfort felt during the opening of the labial rima (before surgery). _____ 6. Indicate the discomfort felt during the extension of the labial rima (before surgery). _____ Rating 3 months. Date……………………….. 1. How much are you satisfied by the aspect of your lips (after surgery)? _____ 2. How much are you satisfied by the skin elasticity of the perioral region (after surgery)? _____ 3. How much are you satisfied by the aspect of the malar (after surgery)? _____ 4. How much are you satisfied by the skin elasticity of the malar region (after surgery)? _____ 5. Indicate the discomfort you feel during the opening of the labial rhyme (after surgery). _____ 6. Indicate the discomfort you feel during the extension of the labial rhyme (after surgery). _____ General evaluation. 7. Will you do again this type of procedure? _____ 8. Would you recommend this procedure to other people with the same disease? _____ |