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Menopause Management Survey
Home
/
Menopause
/ Menopause Management Survey
Menopause Management
There are only a few steps to get started.
Choose your Location
—Please choose an option—
Abu Dhabi
Al Ain
Dubai
Sharjah
Ajman
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What is your date of birth?
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Are you still menstruating?
Yes
No
How long has it been since your last period?
Less than 12 months
1-10 years
More than 10 years
Continue
Please explain why you stopped menstruating:
My periods stopped naturally
I am on hormone therapy (e.g., continuous birth control pills or IUD)
I am using a medication (e.g., chemotherapy or anti-estrogen medicines for cancer)
I had a hysterectomy or endometrial ablation
How long has it been since your last period?
Less than 12 months
1-10 years
More than 10 years
Which of the following best describes your cycle?
I am using birth control that gives me regular periods or no periods
I am regular on the same schedule I have always been
I am increasingly irregular, or the timing, heaviness, of my periods has changed
Continue
Do you still have your ovaries?
Yes
No
How long ago was your hysterectomy/ablation?
Less than 12 months
1-10 years
More than 10 years
Continue
Please select which symptoms you are currently experiencing
Hot flashes
Night sweats
Sleep disturbances outside of night sweats
Mood changes
Vaginal symptoms
Breast discomfort
Urinary symptoms
Changes in body weight
Changes in skin, hair or nails
Gastrointestinal changes
How many hot flashes per day?
1
2
3
4
5
6
7
8
9
10
10+
Please indicate the impact of hot flashes on your quality of life from low (1) to High (7).
1
2
3
4
5
6
7
How many nights per week do you experience night sweats?
1
2
3
4
5
6
7
Please indicate the impact of night sweats on your quality of life from low (1) to High (7).
1
2
3
4
5
6
7
What types of sleep disturbances do you experience?
Daytime fatigue
Insomnia
Racing thoughts
Restless legs
Please indicate the impact of these sleep disturbances on your quality of life.
1
2
3
4
5
6
7
What types of mood symptoms? Check all that apply.
Anxiety
Depression
Extremely “up” mood
Irritability
Mood swings
Panic
Racing thoughts
Rage
Ruminating (turning one thing over and over in your head)
Short temperedness
Suicidality
Tearfulness
Unusual energy
Please indicate the impact of these mood issues on your quality of life.
1
2
3
4
5
6
7
What types of vaginal symptoms?
Change in smell
Discharge
Dryness
Inability to allow penetration
Infections
Itching / burning
Laxity
Pain with intercourse
Please indicate the impact of the vaginal symptoms on your quality of life.
1
2
3
4
5
6
7
Please indicate the impact of breast discomfort on your quality of life.
1
2
3
4
5
6
7
What types of urinary symptoms?
Blood in urine 🡪 Having blood in your urine can be signs of a serious condition and we recommend that you see your doctor for an exam as soon as possible. SURVEY STOPS HERE
Frequent infections
Incontinence – constant dripping
Incontinence – stress (cough, laugh, exercise)
Incontinence – urge (can’t get to bathroom once urge hits)
Kidney stones
Painful bladder
Please indicate the impact of the urinary symptom on your quality of life.
1
2
3
4
5
6
7
What types of body weight issues?
Body image issues
Gain
Intentional loss
Unintentional loss
Redistribution
Please indicate the impact of these body weight symptoms on your quality of life.
1
2
3
4
5
6
7
What types of changes to skin, hair or nails? Check all that apply.
Coloration changes in the skin
Dry skin
Head or body hair growth pattern changes
Itchy skin
Nail changes
Please indicate the impact of these skin, nails or hair symptoms on your quality of life.
1
2
3
4
5
6
7
What types of gastrointestinal issues?
Diarrhea
Early satiety (feeling full quickly)
Food intolerances
Gas / bloating
Nausea
Pain around anus
Rectal bleeding 🡪 Rectal bleeding can be a sign of a serious condition and we recommend that you see your doctor for an exam as soon as possible. SURVEY STOPS HERE
Continue
Please indicate the impact of these gastrointestinal symptoms on your quality of life.
1
2
3
4
5
6
7
Continue
Anything else you would like us to know?
Yes
No
Tell us about any concerns or questions you have for the medical team.
Continue
How would you like to pay?
Out of pocket
Insurance
upload emirates insurance details (if available)
Upload a Photo of your Emirates ID
Upload Front
Upload Back
Back
Continue
Billing and delivery details
Google Map
Delivery Location
Google Map: (Please Share your Google Map Link)
Delivery Location Neighborhood/Area:
Street Name/No:
Address Details:
Back
Continue
Personal Details
Title:
Mr.
Ms.
First Name:
Last Name:
Date of Birth:
Mobile Number:
E-mail:
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Continue
Confirm Request and Agree to Terms
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.
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