Asthma Survey


    Choose your Location

    What is your date of birth?

    Have you had prescription medicine for asthma before?

    Which asthma medication have you previously used?

    Which of the following symptoms do you experience?

    How frequently do you have these symptoms?

    How frequently do you get asthma symptoms at night?

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

    Does asthma limit your ability to do activities?

    When do asthma symptoms occur?

    What seems to trigger your asthma?

    Do your symptoms come and go?

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

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

    Do you have seasonal allergies or hayfever?

    Which of the following could exacerbate your symptoms?

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

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

    Have you been diagnosed with any of the following conditions?

    Have you had breathing tests to evaluate your breathing?

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

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

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

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

    Please list your drug allergies and what happens when you use that drug.

    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.

    In order for us to provide you with the best care, please let us know what medications you take and what conditions you have.

    Do you have any of these conditions?

    Do you….?

    Anything else you would like us to know?

    Tell us about any concerns or questions you have for the medical team.

    How would you like to pay?

    upload emirates insurance details (if available)

    Billing and delivery details

    Google Map: (Please Share your Google Map Link)
    Delivery Location
    Street Name/No:
    Address Details:

    Personal Details

    First Name: Last Name:
    Mobile Number: E-mail:

    Confirm Request and Agree to Terms