Colorado Dermatology Center

Liposculpture Questionnaire

Name:

Street Address:

City:

State:

Zip:

Business Phone:

Home Phone:

Cell Phone:

Fax:

Age:

Sex: Male Female

Married Divorced Widowed Single

Which body areas would you be interested in treating with liposculpture? Check all applicable boxes

Clicking on "view photos" will take you to a section where you can view photos
organized by age, sex, and body area.

Skin Tone:

Firm

Moderately Firm

Flabby

Wrinkled

Soft

Cellulite (Dimples in Skin on Thighs and Buttocks):

None

A Few

Many

Stretch Marks - Indicate Areas and Severity	Abdomen	Fresh (pink or red)	Old (white)	A Few	Many
	Midriff(Above Naval)	Fresh (pink or red)	Old (white)	A Few	Many
	Hips	Fresh (pink or red)	Old (white)	A Few	Many
	Buttocks	Fresh (pink or red)	Old (white)	A Few	Many
	Thighs or Other Areas	Fresh (pink or red)	Old (white)	A Few	Many

EXERCISE LEVEL

Personal Trainer?	Yes	No
Do you:
Walk For Exercise?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Run?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Aerobics?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Bike?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Swim?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Aquacise?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Rowing Machine?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Treadmill?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Stairs or Stair Stepper?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Stretching or Yoga?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Lifting Weights?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week
Other?	Not At All	1 to 2 days per week	3 to 5 days per week	6 to 7 days per week

Smoke?	Yes	No	Previous Liposuction?	Yes	No	Abdominal Surgery?	Yes	No
Diet Pills?	Yes	No	Abdominal Scars?	Yes	No	Very Heavy at One Point in Your Life?	Yes	No

For Prices Call (303)744-1202

Could you come to Colorado for your Surgery?

Yes

Which days would you be available for your surgery?

Monday

Tuesday

Wednesday

Thursday

Friday

Which months would you be available for surgery?

January	February	March	April	May	June
July	August	September	October	November	December

Would you like a free virtual consulation?

Would you like to mail photos to us for a free professional opinion letter? Send to:

Colorado Dermatology Center
950 East Harvard Avenue, Suite 630
Denver, Colorado 80210

If you click below, your personal information and questionnaire will be transmited to the Colorado Dermatology Center(by doing so, you give permission for us to contact you and release your right to privacy in this regard.)