1.Name

2.Is this survey before of after your surgery?

Before

After

Other (please specify)

3.FACE-QTM - SATISFACTION WITH NOSE
For each question, circle only one answer. With your nose in mind, in the past week, how satisfied or dissatisfied have you been with:

Very Dissatisfied

Somewhat Dissatisfied

Somewhat Satisfied

Very Satisfied

The width of your nose at the bottom (from nostril to nostril)?

The length of your nose?

How the bridge of your nose looks (where glasses sit)?

How well your nose suits your face?

How straight your nose looks?

The overall size of your nose?

The shape of your nose in profile (side view)?

How your nose looks in photos?

How the tip of your nose looks?

How your nose looks from every angle?

4.NASAL OBSTRUCTION SYMPTOM EVALUATION (NOSE) Score

Over the past 1 month, how much of a problem were the following conditions for you?

No problem

Mild

Moderate

Severe

Very severe

Nasal congestion or stuffiness ('snotty')

Nasal blockage or obstruction

Trouble breathing through my nose

Trouble sleeping

Unable to get enough air through my nose during exercise

5.Rhinoplasty Outcome Evaluation (ROE) Part 1

Absolutely not

A little

More or less

A lot

Absolutely yes

Do you like the appearance of your nose?

Do you breathe well through you nose?

Do you think that your friends and people dear to you like your
nose?

Do you think that the current appearance of your nose hinders your
social or professional activities?

Do you think that the appearance of your nose is the best that it
could be?

6.Rhinoplasty Outcome Evaluation (ROE) Part 2

Sure I would

Probably yes

Possibly yes

Possibly no

Certainly no

Would you have surgery (or repeat surgery) to alter the appearance of your nose or to improve your breathing?