Facelift Evaluator
Please fill out the following questionnaire to help us determine if a facelift procedure is right for you.
All information is kept confidential.

Question 1 of 11

What is your gender?
Male
Female

Question 2 of 11

What is your age?
Under 40
40-50
51-60
61-70
Over 70

  

Question 3 of 11

How is your physical health?
Have not experienced any health problems
Have only had minor health problems
Have experienced previous major health problems
Have current health problems

  

Question 4 of 11

Are you taking any medications?
No
Yes:

  

Question 5 of 11

Which areas do you want to improve? (Check all that apply)

Midface sagging Deep creases below the eyes
Deep creases along the nose and mouth Jowls
Displaced or fallen fat Loose skin
Double Chin Skin laxity eyes
Brows Skin tone
Skin Discolorations Fine Wrinkles around mouth, eyes
Low eyebrows  

  

Question 6 of 11

Do you smoke?
No
Yes

  

Question 7 of 11

How would you classify your weight?
Underweight
Normal
Slightly overweight
Heavy

  

Question 8 of 11

What's your skin type?
Dry
Normal
Oily
Combination

  

Question 9 of 11

How much sun exposure have you had throughout your lifetime?
Very little
Moderate
Heavy

  

Question 10 of 11

How would you describe your bone structure?
Strong / Well Defined
Medium
Small

  

Question 11 of 11

Has your skin retained its elasticity?
No
Yes
Not sure