◆ Important Notice — Email Communication
By returning this questionnaire by email you acknowledge and consent to the communication of your personal and medical information via email. While reasonable safeguards are in place, email is not a fully secure method of communication. If you prefer not to communicate medical information by email, please call the office at 613·591·1188 to arrange an alternative.
◆ Section I — Patient Information
Tell us about you.
Basic information to prepare for your consultation.
Weight history (describe any significant weight changes, bariatric surgery, or rapid loss/gain)
Smoking & vaping status
Never smoker
Current smoker
Ex-smoker
Vape / nicotine pouch
If current — amount / day
Are you planning future pregnancies?
No
Possibly
Yes
N/A
◆ Section II — Medical & Surgical History
Your medical background.
Medical conditions
Previous surgeries & year (especially abdominal or pelvic: C-section, hysterectomy, appendix, hernia repair)
Anaesthesia history (reactions, nausea, family history of malignant hyperthermia)
Current medications (prescription, OTC, hormones, blood thinners, supplements)
Allergies (medications, latex, tape, anaesthetic agents)
◆ Section III — Abdominal & Weight History
Number of pregnancies / children
Known diastasis recti (separated abdominal muscles)? (diagnosed or suspected)
Yes — diagnosed
Suspected
No
Unsure
Any known abdominal hernias? (umbilical, incisional, inguinal — specify)
Existing abdominal scars (location, cause, approximate year)
◆ Section IV — Aesthetic Concerns & Body Areas
What concerns you most?
Tick all areas of concern and rate how bothered you are (1 = mild, 10 = very bothered).
Loose / excess abdominal skin
Abdominal fat — lower abdomen
Abdominal fat — upper abdomen
Abdominal wall weakness / bulge
Stretch marks
Overhanging skin (pannus)
C-section shelf / scar
Flanks / love handles
Mons pubis fullness
Back rolls / bra fat
Waist definition
Umbilical shape / position
Are you interested in liposuction in addition to the tummy tuck?
Yes — abdomen only
Yes — flanks / love handles
Yes — Lipo 360 (abdomen, flanks, back)
No / unsure
Discuss
If Lipo 360 — which specific areas would you like addressed? (upper back, mid-back, lower back, flank, hip)
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
These preferences guide our discussion — nothing is binding until finalised together at your consultation.
Primary motivation for considering surgery
Restore pre-pregnancy/pre-weight-loss body
Personal confidence & clothing fit
Physical comfort (skin irritation, rash)
Combination of above
Other
Desired silhouette
Flat, smooth abdomen
Defined waistline
Athletic / toned appearance
Natural improvement — not dramatic
Discuss
How do you feel about scars? (the low transverse scar is permanent but hidden under most underwear/swimwear)
Acceptable — understand the trade-off
Concerned — want to discuss scar management
Seek minimum scar — mini-tuck may interest me
Acceptable recovery window
2–3 weeks
3–5 weeks
5–8 weeks
Flexible
Is your weight stable? (abdominoplasty results are best maintained at a stable weight)
Yes, stable >6 months
Still losing weight
Using Ozempic / GLP-1 agonist
Fluctuating
In your own words — what would a great result look like?
Anything that worries you about the procedure or recovery?
◆ Section VI — Occupation & Lifestyle
Your life outside surgery.
Recovery planning is individualised. Telling us about your day-to-day helps us tailor post-operative care to you.
Occupation & physical demands (sedentary, moderate, heavy lifting, driving, on your feet all day)
Planned time off work
1–2 weeks
2–4 weeks
4–6 weeks
More than 6 weeks
Flexible
Exercise routine (type, frequency, intensity)
Home support after surgery (help available for first 72–96 hours; assistance with children, household tasks)
Caring for young children or dependents?
Yes — young children
Yes — other dependents
No
Timing & events (travel, weddings, vacations, obligations within 3–6 months)
How did you hear about Dr. Jaberi?
Referring physician
Friend / family
Instagram
Google
Website
Other
Anything else you would like Dr. Jaberi to know?
I confirm that the information I have provided is accurate to the best of my knowledge. I understand that complete and truthful disclosure is essential for my safe surgical care.