◆ 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.
Smoking & vaping status
Never smoker
Current smoker
Ex-smoker
Vape / nicotine pouch
If current — amount / day
Testosterone replacement therapy (TRT) or anabolic steroid use?
No — never
Current TRT
Past TRT
Anabolic steroids — past
Anabolic steroids — current
Have hormone levels been assessed? (testosterone, estrogen, LH, FSH — provide results if available)
◆ Section II — Medical & Surgical History
Your medical background.
Medical conditions (liver disease, kidney disease, thyroid, Klinefelter syndrome, testicular tumour, other hormonal conditions)
Previous surgeries & year
Anaesthesia history
Current medications (especially: spironolactone, finasteride, anti-androgens, antipsychotics, antidepressants, proton-pump inhibitors, digoxin)
Allergies
◆ Section III — Gynecomastia History
When did gynecomastia start?
Has the condition been worked up by a physician? (blood work, imaging — describe findings)
Is there breast pain or tenderness?
Yes — ongoing
Yes — intermittent
No
Any nipple discharge?
Yes — describe below
No
◆ Section IV — Symptoms & Aesthetic Concerns
How gynecomastia affects you.
Tick all that apply and rate the severity (1 = mild, 10 = most severe).
Enlarged breast tissue — right
Enlarged breast tissue — left
Puffy / protruding nipples
Excess chest fat
Tenderness / pain
Skin laxity / loose skin
Visible through clothing
Avoidance of shirtless activities
Emotional / psychological impact
Degree of chest asymmetry
Symmetric
Mildly asymmetric
Significantly asymmetric
What activities or situations are most affected? (swimming, gym, dating, work, social events)
Type of tissue you believe is present (mostly glandular, mostly fat, or a combination)
Mostly firm glandular tissue
Mostly fatty tissue
Combination
Unsure
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
Primary goal
Flat, masculine chest contour
Reduce nipple protrusion
Remove all excess tissue
Achieve symmetry
Discuss
How important is minimal visible scarring?
Very important
Somewhat important
Not a concern
Are you interested in liposuction of the chest / pseudogynecomastia component?
Yes
Possibly
Glandular removal only
Discuss
Acceptable recovery window
Less than 1 week
1–2 weeks
2–4 weeks
Flexible
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 routine (upper body activities restricted ~3–4 weeks)
Home support after surgery
Timing & events (gym, beach, travel 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.