◆ 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 (especially blood thinners, anti-inflammatory drugs)
Allergies
◆ Section III — Weight & Body History
Prior liposuction?
Never
Yes — describe area & year:
Prior J-Plasma or radiofrequency skin tightening?
Never
Yes — describe:
Comfort with being awake during a procedure
Comfortable — prefer local anaesthesia
Slight anxiety — would want more sedation
Prefer general anaesthesia if available
Discuss in consultation
◆ Section IV — Treatment Area & Concerns
Where would you like treatment?
Tick all areas of interest. You may select as many as apply — Dr. Jaberi will confirm the optimal combination.
Liposuction areas of interest
Abdomen (upper)
Abdomen (lower)
Flanks / love handles
Back rolls
Inner thighs
Outer thighs
Upper arms
Knees
Neck / chin (submental)
Chest / pectoral
Ankles / calves
Other — specify below
J-Plasma skin tightening areas of interest
Abdomen
Flanks
Inner thighs
Upper arms
Back
Neck
Same as lipo areas
Not interested in J-Plasma
Discuss in consultation
Current skin quality in areas of concern
Good tone — minimal laxity
Moderate laxity
Significant laxity
Unsure
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
Primary goal
Fat removal only
Skin tightening only
Fat removal + skin tightening combined
Body contouring — overall silhouette
Discuss
Degree of change desired
Subtle refinement
Moderate improvement
Maximum achievable result
Tolerance for post-procedure bruising, swelling, and temporary irregularities
Acceptable — understand it resolves
Concerned — want to discuss timeline
Have a specific event by:
Compression garment compliance (worn ~4–6 weeks post-op)
Fully committed
Manageable
Concerned — want to discuss
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
2–3 days
Less than 1 week
1–2 weeks
Flexible
Exercise routine (light activity resumes ~1–2 weeks; strenuous activity ~4–6 weeks)
Home support after surgery
Timing & events (beach, travel, photo events 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.