—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman
YesNo
How long has it been since your last period? Less than 12 months1-10 yearsMore than 10 years
My periods stopped naturallyI 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
Which of the following best describes your cycle? I am using birth control that gives me regular periods or no periodsI am regular on the same schedule I have always beenI am increasingly irregular, or the timing, heaviness, of my periods has changed
How long ago was your hysterectomy/ablation? Less than 12 months1-10 yearsMore than 10 years
Hot flashesNight sweatsSleep disturbances outside of night sweatsMood changesVaginal symptomsBreast discomfortUrinary symptomsChanges in body weightChanges in skin, hair or nailsGastrointestinal changes
How many hot flashes per day? 1234567891010+
Please indicate the impact of hot flashes on your quality of life from low (1) to High (7). 1234567
How many nights per week do you experience night sweats? 1234567
Please indicate the impact of night sweats on your quality of life from low (1) to High (7). 1234567
What types of sleep disturbances do you experience? Daytime fatigueInsomniaRacing thoughtsRestless legs
Please indicate the impact of these sleep disturbances on your quality of life. 1234567
What types of mood symptoms? Check all that apply.AnxietyDepressionExtremely “up” moodIrritabilityMood swingsPanicRacing thoughtsRageRuminating (turning one thing over and over in your head)Short temperednessSuicidalityTearfulnessUnusual energy
Please indicate the impact of these mood issues on your quality of life.1234567
What types of vaginal symptoms? Change in smellDischargeDrynessInability to allow penetrationInfectionsItching / burningLaxityPain with intercourse
Please indicate the impact of the vaginal symptoms on your quality of life.1234567
Please indicate the impact of breast discomfort on your quality of life.1234567
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 HEREFrequent infectionsIncontinence – constant drippingIncontinence – stress (cough, laugh, exercise)Incontinence – urge (can’t get to bathroom once urge hits)Kidney stonesPainful bladder
Please indicate the impact of the urinary symptom on your quality of life.1234567
What types of body weight issues? Body image issuesGainIntentional lossUnintentional lossRedistribution
Please indicate the impact of these body weight symptoms on your quality of life. 1234567
What types of changes to skin, hair or nails? Check all that apply. Coloration changes in the skinDry skinHead or body hair growth pattern changesItchy skinNail changes
Please indicate the impact of these skin, nails or hair symptoms on your quality of life. 1234567
What types of gastrointestinal issues? DiarrheaEarly satiety (feeling full quickly)Food intolerancesGas / bloatingNauseaPain around anusRectal 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
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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) Delivery Location Neighborhood/Area: Street Name/No: Address Details:
Title: Mr.Ms. First Name: Last Name: Date of Birth: 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.
