Menopause Management Survey

Menopause Management

There are only a few steps to get started.

    Choose your Location

    What is your date of birth?

    Are you still menstruating?

    How long has it been since your last period?

    Please explain why you stopped menstruating:

    How long has it been since your last period?

    Which of the following best describes your cycle?

    Do you still have your ovaries?

    How long ago was your hysterectomy/ablation?

    Please select which symptoms you are currently experiencing

    How many hot flashes per day?

    Please indicate the impact of hot flashes on your quality of life from low (1) to High (7).

    How many nights per week do you experience night sweats?

    Please indicate the impact of night sweats on your quality of life from low (1) to High (7).

    What types of sleep disturbances do you experience?

    Please indicate the impact of these sleep disturbances on your quality of life.

    What types of mood symptoms? Check all that apply.

    Please indicate the impact of these mood issues on your quality of life.

    What types of vaginal symptoms?

    Please indicate the impact of the vaginal symptoms on your quality of life.

    Please indicate the impact of breast discomfort on your quality of life.

    What types of urinary symptoms?

    Please indicate the impact of the urinary symptom on your quality of life.

    What types of body weight issues?

    Please indicate the impact of these body weight symptoms on your quality of life.

    What types of changes to skin, hair or nails? Check all that apply.

    Please indicate the impact of these skin, nails or hair symptoms on your quality of life.

    What types of gastrointestinal issues?

    Please indicate the impact of these gastrointestinal symptoms on your quality of life.

    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
    Neighborhood/Area:
    Street Name/No:
    Address Details:

    Personal Details

    Title:
    First Name: Last Name:
    Date of Birth:
    Mobile Number: E-mail:

    Confirm Request and Agree to Terms