Eyesthetica Eyelid Surgery Self Test Form What is your first name?* What is your last name?* What is your email address?* (So that we can provide you with the results to this quiz)Please provide the best phone number to reach you at*Are you male or female?* Male Female Other How old are you?* 39 or less 40 - 59 60+ Do you smoke?* Yes No Do you have excess skin, puffiness, drooping or wrinkles of the upper eyelids?* Yes No Do your upper eyelids hang low enough to block your vision or have skin that touches or hangs over your eyelashes?* Yes No Do you have puffy or baggy lower eyelids?* Yes No On your lower eyelid, do you have the appearance of excess skin?* Yes No Does your lower eyelid skin and face have deep wrinkles and spots noticeable when you are not smiling?* Yes No Do you have saggy, low set eyebrows?* Yes No
