◆ 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
Parity (pregnancies / deliveries)
Planning future pregnancies?
No
Possibly
Yes — within 1 year
Yes — timeframe unknown
Contraception method (if applicable)
◆ Section II — Medical & Surgical History
Your medical background.
Significant medical conditions
Previous surgeries & year
Current medications & supplements
Allergies
◆ Section III — Gynaecologic History
Current gynaecologist / OB-GYN?
Most recent PAP smear / pelvic exam
History of recurrent yeast infections, vulvodynia, or vulvar skin conditions?
None
Recurrent yeast
Vulvodynia
Lichen sclerosus
Other — describe:
History of prior vulvar or vaginal surgery?
No
Episiotomy
Perineal repair
Prior labiaplasty
Other — describe:
◆ Section IV — Symptoms & Aesthetic Concerns
How this affects you.
Tick all that apply and rate the severity (1 = mild, 10 = most severe).
Physical discomfort — daily activities
Discomfort with exercise / cycling
Discomfort with tight clothing
Discomfort during intimacy
Hygiene difficulties
Recurrent irritation / chafing
Visible protrusion through swimwear
Aesthetic dissatisfaction
Psychological / emotional impact
Which area is your primary concern?
Labia minora — both sides
Labia minora — left only
Labia minora — right only
Labia majora
Clitoral hood
Discuss in consultation
Primary motivation
Functional relief (physical comfort)
Cosmetic improvement
Both equally
Any sensitivity concerns? (hypersensitivity, decreased sensation)
◆ Section V — Treatment Goals & Preferences
What outcome matters most?
Degree of reduction desired
Subtle — conservative reduction
Moderate reduction
Maximal reduction
Discuss in consultation
Importance of natural-appearing result vs. symmetry
Natural appearance priority
Strict symmetry priority
Both equally
Discuss
Are you interested in any of the following? (tick all applicable)
Clitoral hood reduction
Labia majora reduction / augmentation
Perineoplasty
None of the above
Discuss
Healing and downtime expectations (typical recovery: 2–4 weeks before activities)
Flexible
Need full recovery in less than 2 weeks
Timing-sensitive event:
In your own words — what does a great result mean to you?
Anything that worries you about this procedure?
◆ 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 (physical activity restricted ~3–4 weeks)
Home support after surgery
Timing & events (travel, active vacation, cycling, special occasions)
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.