◆ 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. If you prefer not to communicate by email, please call the office at 613·591·1188.
◆ Section I — Patient Information
Tell us about you.
Is your weight currently stable?
Yes — stable for 6+ months
Mostly stable
Still losing weight
Fluctuates
Smoking & vaping status
Never smoker
Current smoker
Ex-smoker
Vape / nicotine
GLP-1 medication use? (Ozempic, Wegovy, Mounjaro, Saxenda)
Current user
Past user — stopped:
Never
◆ Section II — Medical & Surgical History
Your medical background.
Significant medical conditions
Previous surgeries & year
Current medications & supplements
Allergies
◆ Section III — Weight & Arm History
How was your highest weight reached?
Gradual weight gain
Post-pregnancy
GLP-1 medication
Bariatric surgery
Ageing
Other
Maximum weight ever lost and over what period?
Prior arm treatments or procedures?
None
Prior liposuction — describe:
Non-surgical skin tightening
Prior arm lift
Lymph node surgery or history of lymphoedema?
No
Yes — describe:
◆ Section IV — Symptoms & Aesthetic Concerns
How this affects you.
Tick all that apply and rate the severity (1 = mild, 10 = most severe).
Hanging skin — upper arm
Arm skin laxity — inner upper arm
Arm skin laxity — elbow area
Excess fat in upper arm
Skin irritation / rash / chafing
Difficulty with clothing sleeves
Avoidance of sleeveless clothing
Arms limit physical activity
Psychological / emotional impact
Which area is your primary concern?
Upper arm only
Elbow / lower arm
Both upper + lower arm
Axilla / armpit folds
Discuss
Is it primarily excess skin, fat, or a combination?
Predominantly skin laxity
Predominantly fat
Combination
Unsure
Scar concerns (arm lift scar runs from armpit to elbow on inner arm)
Scar is acceptable given the result
Concerned — want to discuss
History of keloid or hypertrophic scars
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
Primary goal
Reduce skin laxity
Reduce excess fat
Contoured, toned arm silhouette
Wear sleeveless clothing comfortably
Discuss
Are you interested in liposuction in combination with your arm lift?
Yes — if appropriate
Open to discussion
Skin excision only
Liposuction only — no excision
Acceptable recovery window
1–2 weeks
2–4 weeks
4–6 weeks
Flexible
Are you planning any other body procedures at the same time?
No
Yes — specify:
Undecided
In your own words — what would a great result look like?
Anything that worries you?
◆ Section VI — Occupation & Lifestyle
Your life outside surgery.
Occupation & physical demands
Planned time off work
Less than 1 week
1–2 weeks
2–4 weeks
Flexible
Exercise & strength training routine (upper body restricted ~4–6 weeks)
Home support after surgery
Timing & events (beach, summer, sleeveless occasion 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.