Sheba GLP-1 Eligibility Form

Answer all assessment questions below
Metric (cm / kg)Imperial (ft / in / lb)
Height (cm)
Weight (kg)
Height (FT)
Inches (In)
Weight (lb)
BMI
BMI*
Full Name

First NameLast Name
Email (Required)*
example@example.com
DATE OF BIRTH*

DayMonthYear

White (Includes any white background. For example, British or Irish traveller)Black (Includes any black background. For example, African, Caribbean or Black British)Middle Eastern (Includes any Middle Eastern background. For example, Arab or Iranian)Prefer not to sayOther

History of heart attack or strokeHeart failureIrregular heart rhythm requiring treatmentPrevious bariatric surgery (gastric bypass, sleeve, band)Chronic Obstructive Pulmonary Disease (COPD)None of the above

PregnantPlanning to be pregnant in next 3 monthsBreastfeedingNone of the above
PregnantPlanning to be pregnant in next 3 monthsBreastfeedingNone of the above

YesI don't take medication for itNo

YesNo
Date of last injection*

DayMonthYear
Date
YesNo
Please tell us what side effects you have experienced and how they impacted you*

Diet onlyExercise onlyWeight loss medicationBariatric surgeryNone of the above

YesNo, not taking or planning to start an oral hormonal contraceptive

None1–7 units8–14 units15+ units

Less than 10kg10–20kg20–30kgMore than 30kgI'm not sure

InstagramGoogleFriend or FamilyEmployer / ColleagueDoctorOther

Cardiovascular DiseaseHypertensionHypercholesterolaemkaChronic Pelvic PainEndometriosisPOTS (Postural Orthostatic Tachycardia Syndrome)Long CovidNone of the above

We’re unable to offer treatment at this stage
Based on your responses, you don’t currently meet the clinical criteria for this programme.

Our eligibility requirements are in place to ensure treatment is safe and appropriate.

If your circumstances change in the future, you’re welcome to complete a new assessment.

Please note that submitting inaccurate information could put your health at risk.

Your application is being reviewed
Based on your answers, we need to carry out a clinical review before confirming your eligibility.

A doctor from our medical team will assess your information within 5–7 working days. They may contact you if any additional details are needed before a decision is made.

Submitting this form does not guarantee approval, it simply initiates the clinical review process. We’ll be in touch by email once a decision has been reached.

Press submit to move to the next step

Success
You’re eligible to proceed

Based on your answers, you meet our initial eligibility criteria for the programme.

The next step is a clinical consultation where one of our prescribing clinicians will review your medical history in detail and confirm that treatment is appropriate and safe for you.

Please note that eligibility at this stage does not guarantee a prescription. Final approval is always subject to clinician assessment.

Press submit to move to the next step

eligibilityOutcome

eligibilityReason

Set Accepted

Set review

Set Rejected

eligibilityReason
REASON_BMI_LT_20
Reason_None_20_25
Reason_None_25_27
Reason_Pain_20_30
Reason_Cardio_25_27
Reason_Cardio_GE_27
Reason_BMI_30
Reason_Contraindication
Should be Empty: