◆ 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.
Skin type (Fitzpatrick I–VI)
Smoking & vaping status
Never smoker
Current smoker
Ex-smoker
Vape / nicotine pouch
If current — amount / day
Alcohol use (frequency and amount per week)
Sun exposure habits (daily, occasional, tanning beds, regular SPF use)
Skincare routine (retinoids, peels, injectables, lasers — please specify)
◆ Section II — Medical & Surgical History
Your medical background.
Please list all relevant items. If none, write "none."
Medical conditions (e.g. hypertension, heart disease, diabetes, thyroid, clotting disorders, autoimmune)
Previous surgeries & year (including any prior facial surgery)
Anaesthesia history (reactions, nausea, family history of malignant hyperthermia)
Current medications (prescription, OTC, hormones, blood thinners, supplements, herbal)
Allergies (medications, latex, tape, anaesthetic agents — describe reaction)
◆ Section III — Facial Ageing History
Prior non-surgical facial treatments (Botox, fillers, thread lifts, laser, RF, ultrasound — specify type and approximate date)
Age when facial changes noticed
Family history of early ageing?
◆ Section IV — Symptoms & Aesthetic Concerns
What concerns you most?
Tick all areas of concern. Indicate the severity from your perspective (1 = mild, 10 = very bothersome).
Jowling along jawline
Neck laxity / banding
Deep nasolabial folds
Marionette lines
Mid-face descent / deflation
Submental fat (double chin)
Loss of jawline definition
Platysmal banding
Sagging cheeks
Excess facial skin
Tired / aged appearance
Under-eye hollowing
Which area bothers you most? (rank top 1–3 from above)
Are you interested in addressing the neck, the face, or both?
Facelift only
Necklift only
Both facelift & necklift
Not sure — discuss
Are you interested in combining with other procedures? (e.g. eyelid surgery, brow lift, fat grafting, rhinoplasty)
Photos / references — describe your aesthetic inspiration or ideal result
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
These preferences guide our discussion. Nothing here is binding — all decisions are finalised together at your consultation.
Primary motivation for considering surgery
Personal confidence
Professional reasons
Life milestone (divorce, retirement, etc.)
Long-standing wish
Other
Desired look (circle what resonates)
Natural / rested
Refreshed but subtle
Noticeable improvement
Significant transformation
Discuss
How important is it that surgery is not obvious to others?
Very important
Somewhat important
Not important
Scar tolerance (scars are hidden in hairline / behind ears — concerns?)
Acceptable recovery window
1–2 weeks
2–4 weeks
4–6 weeks
Flexible
In your own words — what would a great result look like?
Anything that worries you about surgery 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 & public-facing demands (role, on-camera presence, client-facing work)
Planned time off work
1–2 weeks
2–3 weeks
3–6 weeks
More than 6 weeks
Flexible
Exercise & activity level (type, intensity, frequency)
Home support after surgery (help available for first 48–72 hours; assistance with daily activities)
Timing & events (travel, significant events, social 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.