Pre-treatment Body Dysmorphic Disorder Screening Pre-treatment Screening Questionnaire "*" indicates required fields Patient Details* First Name Last Name Date of Birth* DD slash MM slash YYYY Email* Are you very worried about your appearance in any way?* Yes No Do these concerns preoccupy you? That is, you think about them a lot and wish that you could worry about them less?* Yes No Do these concerns cause you a lot of distress, torment or pain? (select the best answer)* No Mild, not too disturbing Moderate, disturbing but still manageable Severe, very disturbing Extreme, disabling Do these concerns cause you any impairment social, occupational or other important areas of functioning?* No Mild, not too disturbing Moderate, disturbing but still manageable Severe, very disturbing Extreme, disabling Do these concerns often significantly interfere with your social life?* No Mild, not too disturbing Moderate, disturbing but still manageable Severe, very disturbing Extreme, disabling Do these concerns often significantly interfere with your school work, job or ability to function in your role?* No Mild, not too disturbing Moderate, disturbing but still manageable Severe, very disturbing Extreme, disabling Do you avoid doing anything because of your appearance concerns?* Yes No Δ
