◆ 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 medical information 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
Are you planning future pregnancies?
No
Possibly
Yes
N/A
Are you considering adding breast implants at the same time? (mastopexy with augmentation)
Yes — want to add volume
Possibly
No — lift only
Discuss
Are you interested in fat transfer to the breast at the same time?
Yes
Possibly
No
Discuss
◆ Section II — Medical & Surgical History
Your medical background.
Medical conditions
Previous surgeries & year (especially breast: augmentation, reduction, biopsy, cyst removal)
Anaesthesia history
Current medications (prescription, OTC, hormones, supplements)
Allergies
◆ Section III — Breast History & Family History
Any abnormal breast imaging findings?
Family history of breast cancer?
None
First-degree relative
Second-degree relative
BRCA positive
Pregnancies & breastfeeding history (number of pregnancies, breastfed yes/no, duration)
If prior breast implants — type, size, placement, and year of insertion
◆ Section IV — Aesthetic Concerns
What concerns you most?
Tick all areas of concern and rate how bothersome each is (1 = mild, 10 = very bothered).
Breast ptosis (drooping / sagging)
Nipple pointing downward
Loss of upper pole fullness
Wide / stretched areolas
Loss of volume after pregnancy
Asymmetry between sides
Overall shape / projection
Skin quality / stretch marks
Bra fit difficulty
Describe what bothers you most in your own words
What cup size would you ideally like to be after surgery? (approximate — exact size is determined together)
Do you have reference photos or inspiration images you would like to share?
Yes — will email with form
Yes — will bring to consultation
No
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
Primary motivation
Restore pre-pregnancy shape
Improve clothing & swimwear fit
Personal confidence
Physical discomfort
Other
Scar tolerance (mastopexy involves scars around the areola and down to the crease; are you comfortable with this trade-off?)
Yes — understand the trade-off
Concerned — want to discuss
Prefer minimum scar approach if possible
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 the procedure or recovery?
◆ Section VI — Occupation & Lifestyle
Your life outside surgery.
Occupation & physical demands
Planned time off work
1 week
1–2 weeks
2–4 weeks
More than 4 weeks
Flexible
Exercise routine (upper body activities will be restricted ~4–6 weeks)
Home support after surgery
Caring for young children or dependents?
Yes — young children
Yes — other dependents
No
Timing & events (travel, weddings, beach holidays 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.