◆ 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 contact lenses?
No
Glasses
Contact lenses
Both
Had LASIK / refractive surgery
Current ophthalmologist or optometrist?
Most recent eye exam
◆ Section II — Medical & Surgical History
Your medical background.
Significant medical conditions (especially thyroid disease, myasthenia gravis, Graves disease, diabetes)
Previous surgeries & year
Current medications & supplements (especially blood thinners, thyroid medications)
Allergies
◆ Section III — Ocular & Eyelid History
Previous eyelid or brow surgery?
None
Prior upper bleph
Brow lift
Other — describe:
Dry eye or tear production problems?
No
Mild — managed with drops
Moderate — ongoing treatment
Yes — seeing specialist
Ptosis (drooping eyelid) assessment — do you raise your brows to open your eyes?
Yes — noticeable forehead compensation
Occasionally
No
Unsure
◆ Section IV — Symptoms & Aesthetic Concerns
How your upper eyelids affect you.
Tick all that apply and rate the severity (1 = mild, 10 = most severe).
Visual field obstruction
Heavy, tired appearance
Redundant upper lid skin
Eye fatigue / brow ache
Asymmetry — lid creases
Skin resting on lashes
Hood covering upper lid
Difficulty applying makeup
Older / angry appearance
Is the concern primarily functional (visual field) or aesthetic?
Primarily functional
Primarily aesthetic
Both equally
Which side is more affected?
Symmetric
Right more prominent
Left more prominent
Have you been told by a physician that your visual field is reduced?
Yes — visual field test performed
Not tested
No
◆ Section V — Treatment Goals & Preferences
What outcome feels right for you?
Desired result
Natural, well-rested appearance
Open, brighter eyes
Functional — restore full visual field
Higher defined lid crease
Discuss
Are you interested in a brow lift at the same time?
Yes — interested
Open to discussion in consultation
Upper eyelid only at this time
Are you interested in lower blepharoplasty at the same time?
Yes — interested
Open to discussion
Upper eyelid only
Acceptable recovery window (bruising resolves ~10–14 days; presentable ~2 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
Do you have active lifestyle or sports activities? (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.