Form

Do you agree to the following?*

I will answer honestly and on my own behalf

I will tell you about any medical conditions I have and medications I take

I have tried to lose weight with lifestlyle changes, including a healthy diet and exercise

I am not trying to get pregnant, and don't have plans to in the next 3 months.

I am not breastfeeding or pregnant

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How old are you?*

18 - 74

Over 75

what is your height in cm?*

What is your weight in kg?*

If you have been referred to by a Tabi Health customer, include full name here.

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Weight Program Assessment
Complete details below. Ensure to answer questions as honest as possible so it will enable our presciber to make an informed decision and prescribe the right medication for you.

What is your biological sex at birth?*

Male

Female

Do you have any of the following conditions?*

Severe Heart Failure

Angina or previous heart attacks

High Blood Pressure

High Cholesterol (Dyslipidaemia)

Diabetes Retinopathy

Kidney disease

Liver disease

Pancreatitis

Ulcerative Colitis or Crohn's disease

History or family history of Thyroid cancer

Gastroparesis (inflammatory bowel disease, stomach or gut problems)

None of the above

Do you have gall bladder or bile duct issues?*

Yes

Do you have diabetes?*

Yes, i have pre-diabetes/diet controlled diabetes

Yes, I take medication for the diabetes

Do you have any of the following? People with lower BMI can still be eligible with certain medical conditions.*

High Blood Pressure

Sleep Apnoea

Asthma

COPD

Polycystic Ovary Syndrome (PCOS)

Peri-Menopause/Menopause

Treatment for depression linked to weight

Knee or hip osteoarthritis

Other

None of the above

Are you pregnant, breastfeeding or trying to conceive (now or in the near future)? *

Yes

Do you have any other medical conditions or if you selected'other' in previous question, please provide details below.

Are you currently using oral hormonal contraception?*

Yes

Do you have any eating disorder or made yourself sick or vomit to loose weight?*

Yes

Have you ever had serious head injury or trauma?*

Yes

Do you have problems with your pancreas?*

Yes

Do you have or been told you have chronic malabsorption synfrome?*

Yes

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Do you take any medication (from your GP, over-the-counter or herbal medication)? *Please do not include any weight loss medication you currently take*

Yes

If yes, give details

Has your dose changed forthe following medications in the past 43 months - Thyroxine, Antidepressants or oral steroids

Yes my dose has changed (up or down) in the last 3 months

No, it hasn't changedor I'm not taking any of these medication.

Have you been diagosed with any of the following conditions:*

Type 1 diabetes

History of inflammatory bowel disease (Ulcerative Colitis or Crohn's) gastroparesis (slow stomach emptying), or a stoma

Liver cirrhosis, liver failure or liver fibrosis

Severe heart failure (breathless at rest)

Severe chronic kidney or renal impairment or an eGFR below 30ml//min

History of gallstone disease

Bariatric surgery in the last 6 months

Any family history of thyroid cancer endocrine disorders like unstable cushings disease or unstable thyroid disease.

I have NOT been diagnosed with any of above conditions

Do you have any allergies?*

Yes

If yes, provide more information

Have you had surgery in the last 6 months?*

Yes

If yes, provide more information

Have you ever been diagnosed with an eating disorder (such as anorexia, binge eating disorder or bulimia) by a healthcare professional? *

Yes

Are you CURRENTLY using or have used any of the following weight loss medication in the past 4 weeks?*

Ozempic (Semaglutide)

Wegovy (Semaglutide)

Mounjaro (Tirzepatide)

Xenical/Orlistat

Saxenda or Victoza (Liraglutide)

Trulicity (dulaglutide)

Mysimba (Nalterone Bupropion)

Another prescription weight loss medication)

I'm not taking any weight loss medications

Have you EVER used any of the following weight loss treatment?*

Ozempic

Wegovy

Saxenda

Mounjaro

Xenical/Orlistat

None of the above

Please add any additional information that could help our prescriber in making the right decision for you.

GP Sugery name and location- We will notify your GP if a supply is made. Your order may be delayed if you do not enter the correct details.*

Are you CURRENTLY taking any of the following medications - Aniodarone, Carbamazepine, Ciclosporin, Clozapine, Digoxin, Fenfluramine, Glibenclamide, Gliclazide, Glimepride, Glipizide, Insulin, Oral Methotrexate, Phenobarbital, Phenytoin, Somatrogon, Tacrolimus, Theophyline, Tolbutamide, Warfarin.*

Yes

If yes, please give more details

Do you have any of the following condition?*

Dependent on opiates or opiates agonists (e.g methadone)

Current or history of seizures

Current or past history of bipolar disorder, or depreon

Serious head injury or head trauma

Heart or circulatory problems

Condition affecting the cirsulation of blood in the brain

Medical condition or take medication that may contribute to your weight gain - Examples include growth hormone deficiency, polycystic ovary syndrome, Cushing's syndrome, hypothyroidism, hypothalamic damage (e.g., tumour, trauma, or surgery)

None of the above

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About You

Enter your details to register and choose your desired treatment.

First Name*

Last Name*

Email*

Phone Number*

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Acknowledgement and consent

Please read and tick information about weight loss medication, acknowledge understanding and consent.

I understand I should use one weight loss product at a time

I understand that I will stop treatment and inform Tabi Health and/or seek medical attention if I experience severe dehydration, e.g. dark urine, confusion, blood in stool or vomit, diarrhoea lasting longer than 72 hours, or being unable to keep food down without vomiting/diarrhoea

I understand that if I experience any troublesome side effects from Wegovy/Mounjaro, I can contact Tabi Health Pharmacy, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient Information Leaflet.

The medical information I have provided is true and accurate to the best of my knowledge, and I consent to the medicine being administered.

I agree to inform my GP of any change to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed.

I understand that my personal information, including name, surname, email, telephone, date of birth (DOB) and GP details, will be securely uploaded to the Tabi Health third party dtabase for electronic storage, and it will be kept in line with data protection regulations along with the details of the consultation (i.e., medicines provided).

I understand that I can speak to a member of staff about any queries regarding this consultation, including exercising my rights under data protection legislation.

I will contact Tabi Health if I start taking any new meidicnes, if my medical conditions chnage, or if I experience side effects.

I will stop treatment and contact my doctor if i develop any lumps in my neck or a hoarse vocie while taking this medication

I understand that this medication may increase the risk of pancreatitis, gallbladder problems, and gallstones. If i experience abdominal pain, I will seek medical advise.

I will read the patient information leaflet provided with my medication

I understand that this medication can make the pill less effective. I should use extra prtection like condoms, during treatment.

Tabi Health is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

I agree to receive further communications from Tabi Health to help with my program

You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

By clicking submit below, you consent to allow Tabi Health to store and process the personal information submitted above to provide you the content requested.

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