What is your date of birth?

Have you had prescription medicine for asthma before?

YesNo

Which of the following symptoms do you experience?

Wheezing a high-pitched sound when breathing outCoughShortness of breath or difficulty breathingChest tightnessHeaviness or chest pressureSharp chest painOtherNone

How frequently do you have these symptoms?

None1 to 2 days a week2 to 7 days a weekEvery dayEvery day and all dayOnly with exercise

How frequently do you get asthma symptoms at night?

Less than once a weekMore than once a week

Do your asthma symptoms seem to worsen or appear during the night?

Symptoms about the same day or nightSymptoms seems to appear or worsen at night

Does asthma limit your ability to do activities?

NoneMinorSomeExtremely

When do asthma symptoms occur?

All year-roundOnly certain times of yearOnly with exerciseOther

What seems to trigger your asthma?

PetsPollenSmoke and fumesPerfumesCleaning agentsDustCold airViral infection like fluOtherNone of the above

Do your symptoms come and go?

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

Do you produce phlegm when you have a flare-up?

I don’t produce phlegmYes, clear or whitish phlegmYes, yellow or color phlegm

Do your asthma symptoms occur more at work/school than at home?

Symptoms occur more at work/schoolSymptoms occur more at homeNo difference between work/school & home

Do you have seasonal allergies or hayfever?

YesNo

Which of the following could exacerbate your symptoms?

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

How soon do you feel shortness of breath after starting to exercise?

Soon after exerciseAbout 5 to 15 minutes after startingAbout 15 minutes after startingNo shortness of breath with exerciseOther

How soon does your shortness of breath improve after stopping to exercise?

Within 5 minutesWithin 30 to 60 minutesI don’t have shortness of breathOther

Have you been diagnosed with any of the following conditions?

Eczema or atopic dermatitisNasal polypsNone of the above

AsthmaAllergies (hay fever)Eczema or atopic dermatitisNone of the above

Have you had breathing tests to evaluate your breathing?

Pulmonary function test (PFT)SpirometryAllergy testingMethacholine challenge testChest x rayCT scanOtherDidn’t perform any test

Do you experience any of the following during an asthma flare-up?

Chest pain (NOT chest tightness)LightheadednessPassing outPalpitationsNone of the above

Have you ever been treated in the hospital for an asthma attack?

YesNo

Please provide your height (cm) and weight (kilograms)

Are you allergic to any medicines? Milk protein? Aspirin, NSAIDs, or phenylalanine?

YesNo

Do you take other medication(s) or have any other medical conditions?

Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

YesNo

Do you have any of these conditions?

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

Do you….?

Smoke cigarettes or use tobacco productsDrink more than 2 alcoholic beverages per dayNone apply

Anything else you would like us to know?

YesNo

How would you like to pay?

Out of pocketInsuranceupload emirates insurance details (if available)

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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.