J

Jaberi Plastic Surgery

Aesthetic Surgery · Ottawa

Document JPS–INT–BR–01
Version 2026.04
Pages 06

Private · Confidential · Pre-Consultation Questionnaire

Breast Reduction
Intake Questionnaire

Thank you for your interest in a breast reduction consultation. Before your appointment, please take a few unhurried minutes to complete this questionnaire. Your answers help us understand your goals and medical background so that your consultation is safe, personalised, and efficient. There are no wrong answers — where you are unsure, simply write “discuss in consultation.”

@doctor.jaberi

◆ What This Form Covers

I.Patient Information & Vitals

II.Medical & Surgical History

III.Breast Health & Family History

IV.Symptoms Related to Breast Size

V.Aesthetic Preferences & Goals

VI.Occupation & Lifestyle

@doctor.jaberi

Patient Name

Date of Birth

Date Completed

Surgeon of Record

Dr. Mehrad Jaberi

MD · CM · MSc · FRCSC

◆ 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 and may be vulnerable to interception or unauthorised access. If you prefer not to communicate medical information by email, please call the office at 613·591·1188 to arrange an alternative. Participation is voluntary and will not affect the care you receive.

◆ Section I — Patient Information

Tell us about you.

Basic information so we can prepare for your consultation.

Age

Occupation

Height

Current Weight

Maximum Weight (past, if different)

Weight Change (amount & over how long)

Weight loss method (diet, exercise, medications e.g. Ozempic/Wegovy, bariatric surgery, other — or n/a)

Children

Breastfed? (yes/no, duration)

Planning more children?

Menstrual status

Smoking & vaping status

Never smoker Current smoker Ex-smoker Vape / nicotine pouch Cannabis smoker

If current — amount

If quit — when?

◆ Section II — Medical & Surgical History

Your medical background.

Please list all relevant items. If none, write “none.”

Medical conditions (e.g. high blood pressure, diabetes, thyroid, asthma, clotting disorders, autoimmune, depression/anxiety)

Previous surgeries & year

Anaesthesia history (any reaction, nausea, or family history of malignant hyperthermia)

Current medications (prescription, OTC, hormones, supplements, herbal)

Allergies (medications, latex, tape, foods — and the reaction)

◆ Section III — Breast Health & Family History

Last mammogram (date & result)

Breast ultrasound (date & result)

Breast biopsy (date & result, if any)

Any breast lumps now?

Family history of breast or ovarian cancer (relation, age at diagnosis, and any known genetic result — e.g. BRCA)

◆ Section IV — Symptoms Related to Breast Size

How your breasts affect your daily life.

Tick each symptom you experience. Rate severity 1–10 where 10 is the most severe, and indicate roughly how long you have had it.

Neck pain

Upper back pain

Lower back pain

Shoulder pain

Shoulder grooving (bra strap marks)

Headaches

Numbness / tingling in arms

Intertrigo / rash under breasts

Difficulty with hygiene

Difficulty finding bras

Exercise limitation

Poor posture

What have you tried so far? (supportive bras, physiotherapy, massage, chiropractor, weight loss, medication, topical care — and whether they helped)

◆ Section IV (cont.) — Bra Sizing

Current bra size

Pre-weight-change size (if different)

Cup size change over time?

About desired size. Most patients prefer a size that is proportionate to their frame. At consultation we will discuss the minimum and maximum cup size that is safely achievable for your anatomy. Your preferred size below is a starting point for that conversation.

Desired cup size

Size you'd never go below

Size you'd never exceed

◆ Section V — Aesthetic Preferences & Goals

What outcome would feel right for you?

These preferences guide the conversation. Nothing here is binding — all choices are finalised together at your consultation. If you are unsure, tick “discuss in consultation.”

Desired areolar size (the pigmented circle around the nipple)

Maintain current Smaller Noticeably smaller Discuss in consultation

Desired nipple position

Higher / more youthful Maintain current Discuss in consultation

Desired breast shape & projection

Round & full Natural slope Proportionate Perky / upper-pole fullness Discuss

Lateral chest wall & axillary improvements (the side of the chest, under the arm — often where a bra band sits)

Address excess skin / laxity Address excess fat / fullness Bra bulge / roll Armpit fullness Create one harmonious breast unit Not a concern

Scar priorities (please rank 1–3: 1 = most important)

Shortest possible scar

Best final shape

Best symmetry & balance

In your own words — what would a great result look like?

Is there anything that worries you about this surgery?

◆ Section VI — Occupation & Lifestyle

Your life outside surgery.

Recovery planning is individualised. Telling us about your day-to-day helps us tailor the post-operative timeline to you.

Occupation & physical demands (role, lifting/standing/reaching, employer accommodations)

Planned time off work

Less than 1 week 1–2 weeks 2–4 weeks More than 4 weeks Flexible

Exercise routine (type, frequency, weight training, contact sports)

Home support after surgery (driver, help with children, help for the first 48–72 hours)

Caring for young children or dependents?

Yes — young children at home Yes — other dependents No

Timing & events (weddings, travel, life events within 6–12 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.

Patient Signature

Date