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What is your date of birth?

Do you experience any of the following symptoms? Select all that apply

Headaches or muscle tensionAches or painChest painHaving trouble falling asleepFeeling scared without any reasonDry mouthOther

Tell us more

On average, do you get 7-8 hours of sleep?

NeverSometimesOftenAlmost Always

Have you noticed any of the following symptoms?

Overreacting to situationsBeing irritated, upset, or furious about trivial issuesBeing nervous for no apparent reasonExperiencing Breathing problemsTurning to unhealthy foods such as junk food or sweets, when feeling stressedHaving panic attacksOther

Tell us more

Select all that apply

Smoking cigarettesDrinking alcoholDrinking caffeine (coffee, tea, or cola)None apply

Average number of daily cigarettes

How many cups a day?

Do you have a supporting social network and do you prioritize relationships in your life?

YesNo

Do you workout on a regular basis?

YesNo

Are you allergic to any medicine?

YesNo

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?

Please include any antibiotics, name of birth control, as well as any over-the-counter and herbal dietary or potassium supplements.

YesNo

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

Anything else you would like us to know?

How would you like to pay?

Out of pocketInsurance upload emirates insurance details (if available) Upload a Photo of your Emirates ID Upload Front Upload Back

Billing and delivery details

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

Personal Details

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

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.

Stress Survey

Stress

Choose your Location

What is your date of birth?

Do you experience any of the following symptoms? Select all that apply

On average, do you get 7-8 hours of sleep?

Are you experiencing any digestive problems?

Have you noticed any of the following symptoms?

Select all that apply

Do you have a supporting social network and do you prioritize relationships in your life?

Do you workout on a regular basis?

Are you allergic to any medicine?

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

Do you have any of these conditions?

Anything else you would like us to know?

How would you like to pay?

Billing and delivery details

Personal Details

Confirm Request and Agree to Terms

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Al Thiqa Al Dowaliah Pharmacy

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