◆ 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.
Skin type (Fitzpatrick scale I–VI)
I (very fair)
II (fair)
III (medium)
IV (olive)
V (brown)
VI (dark)
Smoking & vaping status
Never smoker
Current smoker
Ex-smoker
Vape / nicotine
Do you wear glasses or contacts?
No
Glasses
Contact lenses
Had LASIK / refractive surgery
Prior under-eye filler injections?
No
Yes — filler type & last treatment:
Current ophthalmologist or optometrist?
◆ Section II — Medical & Surgical History
Your medical background.
Significant medical conditions (thyroid disease, Graves disease, allergies with eye involvement)
Previous surgeries & year
Current medications & supplements
Allergies
◆ Section III — Ocular & Eyelid History
Previous eyelid or brow surgery?
None
Prior lower bleph
Prior upper bleph
Other — describe:
Dry eye or tear production problems?
No
Mild — managed with drops
Moderate — ongoing treatment
Yes — seeing specialist
Lower lid laxity (snap test — does lower lid return slowly?)
Returns quickly (normal)
Returns slowly
Unsure — not tested
◆ Section IV — Symptoms & Aesthetic Concerns
How your lower eyelids affect you.
Tick all that apply and rate the severity (1 = mild, 10 = most severe).
Under-eye bags / puffiness
Under-eye hollows / tear trough
Dark circles
Wrinkled lower lid skin
Lower lid skin laxity
Asymmetry — lower lids
Tired / aged appearance
Concavity / sunken area
Skin texture / fine lines
What best describes your under-eye concern?
Excess fat (bags)
Hollowness / lack of volume
Both fat and hollow
Skin laxity / crepe
Combination — all of the above
Which side is more affected?
Symmetric
Right more prominent
Left more prominent
Does the concern worsen with fatigue, allergies, or fluid intake?
Yes — noticeable variation
Somewhat
Constant, regardless
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
Desired result
Remove puffiness / bags
Smooth tear trough / hollow
Reduce skin laxity / wrinkles
Refreshed, rested look
Discuss
Are you interested in fat repositioning vs. pure excision?
Open to repositioning — fuller result
Remove fat only
Discuss in consultation
Are you interested in skin resurfacing (laser, chemical peel) at the same time?
Yes
Open to discussion
Surgery alone at this time
Are you interested in upper blepharoplasty at the same time?
Yes
Open to discussion
Lower only
Acceptable recovery window (bruising resolves ~10–14 days; final result at 6–8 weeks)
Less than 2 weeks
2–4 weeks
Flexible
Have a specific date by:
In your own words — what would a great result look like?
Anything that worries you?
◆ Section VI — Occupation & Lifestyle
Your life outside surgery.
Occupation & screen / visual demands
Planned time off work
Less than 1 week
1–2 weeks
2–4 weeks
Flexible
Exercise routine (strenuous activity restricted ~3–4 weeks)
Home support after surgery
Timing & events (presentation, travel, social event within 3–6 weeks)
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.