Pre- and post-operative Rhinoplasty assessment

Results are used for audit purposes
Your name is to match up the pre- and post-operative scores
(otherwise all data is anonymised)

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1. Name

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2. Is this survey before of after your surgery?

Before

After

Other (please specify)

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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 width of your nose at the bottom (from nostril to nostril)? Very Dissatisfied	The width of your nose at the bottom (from nostril to nostril)? Somewhat Dissatisfied	The width of your nose at the bottom (from nostril to nostril)? Somewhat Satisfied	The width of your nose at the bottom (from nostril to nostril)? Very Satisfied
The length of your nose?	The length of your nose? Very Dissatisfied	The length of your nose? Somewhat Dissatisfied	The length of your nose? Somewhat Satisfied	The length of your nose? Very Satisfied
How the bridge of your nose looks (where glasses sit)?	How the bridge of your nose looks (where glasses sit)? Very Dissatisfied	How the bridge of your nose looks (where glasses sit)? Somewhat Dissatisfied	How the bridge of your nose looks (where glasses sit)? Somewhat Satisfied	How the bridge of your nose looks (where glasses sit)? Very Satisfied
How well your nose suits your face?	How well your nose suits your face? Very Dissatisfied	How well your nose suits your face? Somewhat Dissatisfied	How well your nose suits your face? Somewhat Satisfied	How well your nose suits your face? Very Satisfied
How straight your nose looks?	How straight your nose looks? Very Dissatisfied	How straight your nose looks? Somewhat Dissatisfied	How straight your nose looks? Somewhat Satisfied	How straight your nose looks? Very Satisfied
The overall size of your nose?	The overall size of your nose? Very Dissatisfied	The overall size of your nose? Somewhat Dissatisfied	The overall size of your nose? Somewhat Satisfied	The overall size of your nose? Very Satisfied
The shape of your nose in profile (side view)?	The shape of your nose in profile (side view)? Very Dissatisfied	The shape of your nose in profile (side view)? Somewhat Dissatisfied	The shape of your nose in profile (side view)? Somewhat Satisfied	The shape of your nose in profile (side view)? Very Satisfied
How your nose looks in photos?	How your nose looks in photos? Very Dissatisfied	How your nose looks in photos? Somewhat Dissatisfied	How your nose looks in photos? Somewhat Satisfied	How your nose looks in photos? Very Satisfied
How the tip of your nose looks?	How the tip of your nose looks? Very Dissatisfied	How the tip of your nose looks? Somewhat Dissatisfied	How the tip of your nose looks? Somewhat Satisfied	How the tip of your nose looks? Very Satisfied
How your nose looks from every angle?	How your nose looks from every angle? Very Dissatisfied	How your nose looks from every angle? Somewhat Dissatisfied	How your nose looks from every angle? Somewhat Satisfied	How your nose looks from every angle? Very Satisfied

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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 congestion or stuffiness ('snotty') No problem	Nasal congestion or stuffiness ('snotty') Mild	Nasal congestion or stuffiness ('snotty') Moderate	Nasal congestion or stuffiness ('snotty') Severe	Nasal congestion or stuffiness ('snotty') Very severe
Nasal blockage or obstruction	Nasal blockage or obstruction No problem	Nasal blockage or obstruction Mild	Nasal blockage or obstruction Moderate	Nasal blockage or obstruction Severe	Nasal blockage or obstruction Very severe
Trouble breathing through my nose	Trouble breathing through my nose No problem	Trouble breathing through my nose Mild	Trouble breathing through my nose Moderate	Trouble breathing through my nose Severe	Trouble breathing through my nose Very severe
Trouble sleeping	Trouble sleeping No problem	Trouble sleeping Mild	Trouble sleeping Moderate	Trouble sleeping Severe	Trouble sleeping Very severe
Unable to get enough air through my nose during exercise	Unable to get enough air through my nose during exercise No problem	Unable to get enough air through my nose during exercise Mild	Unable to get enough air through my nose during exercise Moderate	Unable to get enough air through my nose during exercise Severe	Unable to get enough air through my nose during exercise Very severe

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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 like the appearance of your nose? Absolutely not	Do you like the appearance of your nose? A little	Do you like the appearance of your nose? More or less	Do you like the appearance of your nose? A lot	Do you like the appearance of your nose? Absolutely yes
Do you breathe well through you nose?	Do you breathe well through you nose? Absolutely not	Do you breathe well through you nose? A little	Do you breathe well through you nose? More or less	Do you breathe well through you nose? A lot	Do you breathe well through you nose? Absolutely yes
Do you think that your friends and people dear to you like your nose?	Do you think that your friends and people dear to you like your nose? Absolutely not	Do you think that your friends and people dear to you like your nose? A little	Do you think that your friends and people dear to you like your nose? More or less	Do you think that your friends and people dear to you like your nose? A lot	Do you think that your friends and people dear to you like your nose? Absolutely yes
Do you think that the current appearance of your nose hinders your social or professional activities?	Do you think that the current appearance of your nose hinders your social or professional activities? Absolutely not	Do you think that the current appearance of your nose hinders your social or professional activities? A little	Do you think that the current appearance of your nose hinders your social or professional activities? More or less	Do you think that the current appearance of your nose hinders your social or professional activities? A lot	Do you think that the current appearance of your nose hinders your social or professional activities? Absolutely yes
Do you think that the appearance of your nose is the best that it could be?	Do you think that the appearance of your nose is the best that it could be? Absolutely not	Do you think that the appearance of your nose is the best that it could be? A little	Do you think that the appearance of your nose is the best that it could be? More or less	Do you think that the appearance of your nose is the best that it could be? A lot	Do you think that the appearance of your nose is the best that it could be? Absolutely yes

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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?	Would you have surgery (or repeat surgery) to alter the appearance of your nose or to improve your breathing? Sure I would	Would you have surgery (or repeat surgery) to alter the appearance of your nose or to improve your breathing? Probably yes	Would you have surgery (or repeat surgery) to alter the appearance of your nose or to improve your breathing? Possibly yes	Would you have surgery (or repeat surgery) to alter the appearance of your nose or to improve your breathing? Possibly no	Would you have surgery (or repeat surgery) to alter the appearance of your nose or to improve your breathing? Certainly no