◆ 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)
Ethnic background (helps contextualize aesthetic goals and nasal anatomy)
Smoking & vaping status
Never smoker
Current smoker
Ex-smoker
Vape / nicotine
Prior rhinoplasty or nasal surgery?
No — primary rhinoplasty
Yes — revision rhinoplasty (number of prior surgeries & year):
How long have you been considering rhinoplasty?
Less than 6 months
1–2 years
More than 3 years
Lifelong concern
◆ Section II — Medical & Surgical History
Your medical background.
Significant medical conditions
Previous surgeries & year
Current medications & supplements
Allergies
◆ Section III — Nasal & Breathing History
Breathing concerns?
No breathing problems
Nasal obstruction — left
Nasal obstruction — right
Both sides
Sleep apnoea
Nasal trauma / fracture history?
None
Yes — describe:
Prior septoplasty or turbinate reduction?
None
Septoplasty
Turbinate reduction
Both
Chronic rhinitis, sinusitis, or nasal polyps?
No
Seasonal allergies
Chronic rhinitis
Sinusitis
Polyps
◆ Section IV — Symptoms & Aesthetic Concerns
What bothers you about your nose?
Tick all that apply. Rate severity 1 (mild concern) to 10 (most significant).
Dorsal hump (bridge)
Bulbous or wide tip
Drooping tip (ptotic)
Crooked / deviated nose
Wide nostrils / flare
Asymmetry (nostrils/tip)
Skin thickness concerns
Wide dorsum / bony width
Breathing / function
Primary motivation
Cosmetic only
Functional only
Both cosmetic & functional
Trauma reconstruction
Revision / correction
Do you have reference photos? (Please bring or send to the office prior to consultation)
Yes — will bring
Yes — can email to office
No reference photos
Prefer imaging / simulation
Can you describe in your own words what specifically bothers you?
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
Desired change to the bridge
Reduce hump
Straighten
Narrow
No change to bridge
Discuss
Desired change to the tip
Refine / narrow
Lift / rotate upward
Project tip further
Deproject tip
No change to tip
Discuss
Desired change to nostrils / base
Narrow nostril flare
Reduce nostril sill
No change to base
Discuss
Breathing improvement — is this a goal?
Not a priority
Yes — included in goals
Primary reason for surgery
Overall aesthetic philosophy
Subtle & natural — change almost invisible
Moderate refinement — recognisable improvement
Significant change — the transformation is the goal
Acceptable recovery window (splint 1 week; swelling 3–6 months; final at 12 months)
Flexible
Have a specific date by:
Anything that worries you?
◆ Section VI — Occupation & Lifestyle
Your life outside surgery.
Occupation
Contact sports / activities (restricted for 6–8 weeks; nose at risk for secondary trauma until fully healed)
No contact sport
Yes — type:
Glasses wearer (glasses cannot rest on the nose for 6–8 weeks post-op)
No
Yes — transitions to contacts manageable
Yes — need a plan for glasses
Planned time off work
Less than 1 week
1–2 weeks
2–4 weeks
Flexible
Exercise routine (strenuous activity restricted ~4–6 weeks)
Home support after surgery
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.