Essential Path Payment Form - Emotional Wellness

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Emotional Wellness

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Personal Information

Name *

Email Address *

Phone *

Date of Birth *

Age *

Nationality *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Country *

Occupation *

Height *

Weight *

Choose from Specialized Services *

Consent *

Yes, I agree with the Terms & Conditions .

Polycystic Ovary Syndrome (PCOS) Support Program

Specify your diet plan

Medical History

Have you been diagnosed with PCOS before? *YesNo

Age of Diagnosis *

Last Menstrual Period *

Do you experience irregular periods? *YesNo

Have you experienced any of the following symptoms of PCOS? *Heavy menstrual bleedingIrregular or missed periodsExcess facial or body hair (hirsutism)AcneThinning hair or hair lossWeight gain or difficulty losing weightDark patches of skin (e.g., on neck, armpits)Skin tagsnone

Do you experience pelvic pain? *YesNo

Lifestyle Information

How often do you exercise? *Rarely or never1–2 times per week3–5 times per weekDaily

What type of diet do you follow? *Standard dietLow-carb or keto dietVegetarian or veganOther (please specify)

Do you experience cravings for sugar or carbohydrates? *YesNo

Do you sleep well at night? *YesNo

Family History

Do you have a family history of any of the following conditions? *DiabetesHypertensionObesityPCOSThyroid issues

Medical Information

Are you currently taking any medications for PCOS or hormonal imbalances? *

Have you been diagnosed with any of the following? *Insulin resistanceType 2 diabetesThyroid disorderHigh cholesterol

Have you undergone any of the following treatments? *Oral contraceptivesMetforminFertility treatmentsOther (please specify)

Other mention here *

What symptoms or concerns related to PCOS are you currently experiencing? *

What are your primary goals in managing PCOS? *

Perimenopause / Menopause Support Program

Last Menstrual Period *

Number of Children (if applicable)

Symptoms of Hormonal Imbalance *Dry skinMuscle painFatigueWeight gainWeight lossMood swingsHair lossConstipationLoss of appetiteIndigestion after foodFeeling coldHot flashesDry vaginaBurning during urination

Perimenopause and Menopause-Related Questions

Are you currently experiencing irregular periods? *YesNo

Have you experienced night sweats? *YesNo

Do you have sleep disturbances or insomnia? *YesNo

Do you experience vaginal dryness or discomfort during intercourse? *YesNo

Have you noticed a reduction in libido? *YesNo

Have you had mood changes like irritability or depression? *YesNo

Do you experience joint or muscle aches that are new? *YesNo

Have you experienced memory problems or brain fog? *YesNo

Additional Information

Any previous surgery *

Any medical problem for which you are taking medicines *

Any important family history like diabetes or hypertension *

Current Brain Health and Lifestyle

How would you rate your current cognitive performance? *ExcellentGoodAveragePoor

Do you experience any of the following cognitive symptoms? *Memory lapses or forgetfulnessDifficulty concentrating or staying focusedBrain fogSlow thinking or processing speedDifficulty with decision-makingDifficulty multitaskingFrequent mental fatigue

Do you feel rested upon waking? *YesNo

How many hours of sleep do you get on average per night? *Less than 4 hours4–6 hours6–8 hoursMore than 8 hours

How often do you exercise? *Rarely or never1–2 times per week3–5 times per weekDaily

What type of diet do you follow? *Standard dietLow-carb or keto dietVegetarian or veganOther (please specify)

Do you consume any of the following regularly? *Processed or junk foodSugary snacks or drinksAlcoholCaffeine (coffee, tea, energy drinks)

Medical and Family History

Do you have a history of any of the following conditions? *Traumatic brain injuryStrokeDepressionAnxietyADHD or ADDAlzheimer's disease or dementiaOther neurological conditions

Do you consume any of the following regularly? *Processed or junk foodSugary snacks or drinksAlcoholCaffeine (coffee, tea, energy drinks)

Are you currently taking any medications for brain or neurological health? *

Brain Activity and Stress

How often do you engage in activities that challenge your brain (e.g., puzzles, learning new skills)? *DailyA few times a weekRarelyNever

How often do you feel stressed? *RarelySometimesFrequentlyConstantly

Do you practice any stress-management techniques? *Meditation or mindfulnessYogaDeep breathing exercisesJournalingPhysical exercise

Current Concerns and Goals

What are your primary concerns related to brain health or cognitive performance? *

What goals do you have for improving your brain health? *

EWC Dubai is a leading wellness center dedicated to enhancing the health and well-being of both men and women. We offer personalized, evidence-based treatments tailored to each individual’s needs. Specializing in perimenopause, menopause, and overall wellness support, our expert team is committed to helping you achieve a healthier, more vibrant life.

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