—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman
Which asthma medication have you previously used?
Wheezing a high-pitched sound when breathing outCoughShortness of breath or difficulty breathingChest tightnessHeaviness or chest pressureSharp chest painOtherNone
None1 to 2 days a week2 to 7 days a weekEvery dayEvery day and all dayOnly with exercise
Less than once a weekMore than once a week
Symptoms about the same day or nightSymptoms seems to appear or worsen at night
All year-roundOnly certain times of yearOnly with exerciseOther
PetsPollenSmoke and fumesPerfumesCleaning agentsDustCold airViral infection like fluOtherNone of the above
My symptoms are constantMy symptoms come and go within a period of hoursMy symptoms come and go within a period of daysI rarely have symptomsOther
I don’t produce phlegmYes, clear or whitish phlegmYes, yellow or color phlegm
Symptoms occur more at work/schoolSymptoms occur more at homeNo difference between work/school & home
Heartburn / gastroesophageal reflux (GERD)Prescription eye dropsHigh blood pressureEating shrimp, dried fruit, processed potatoesTaking aspirinAnti-inflammatories or non-steroidal anti-inflammatories (NSAIDS)Drinking beer or wineNone of the above
Soon after exerciseAbout 5 to 15 minutes after startingAbout 15 minutes after startingNo shortness of breath with exerciseOther
Within 5 minutesWithin 30 to 60 minutesI don’t have shortness of breathOther
Eczema or atopic dermatitisNasal polypsNone of the above
AsthmaAllergies (hay fever)Eczema or atopic dermatitisNone of the above
Pulmonary function test (PFT)SpirometryAllergy testingMethacholine challenge testChest x rayCT scanOtherDidn’t perform any test
Chest pain (NOT chest tightness)LightheadednessPassing outPalpitationsNone of the above
Please list your drug allergies and what happens when you use that drug.
Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.
In order for us to provide you with the best care, please let us know what medications you take and what conditions you have.
Kidney problems including having had a kidney transplantLiver problemsSeizure disorder or epilepsyHistory or family history of QT prolongationGlaucoma, cataracts, or high intraocular pressureOsteoporosisHistory or currently have tuberculosis (TB)DiabetesHigh blood pressureHigh cholesterolHeart disease or heart attackMyasthenia gravisSclerodermaHIVCancer or history of cancerThyroid or other hormone conditionMigraine headachesPregnantBreastfeedingNone apply
Smoke cigarettes or use tobacco productsDrink more than 2 alcoholic beverages per dayNone apply
Tell us about any concerns or questions you have for the medical team.
Out of pocketInsuranceupload emirates insurance details (if available)
Google MapDelivery Location Google Map: (Please Share your Google Map Link)
First Name: Last Name:
Mobile Number: E-mail:
After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.