Your e-Consultation Form

Thank you for signing up to the e-consultation. The next step is to complete the following form. There is quite a bit of detail but the more comprehensively you complete the form, the more value Tabitha can give to you.

Everything is required and if you have nothing to add to a section please just type N/A. The form will not allow you to submit anything unless everything has been completed.

  • Format: (011)123-4567
  • Medical Aid and GP Details

  • Medical aid email address where we can submit the paid receipt
  • Format: (011)123-4567
  • Personal Info

  • Do you suffer from any of the following disorders?

  • Please complete the following section as accurately as you can.

    Record exactly what you ate and drank yesterday from when you first woke up, until you went to sleep last night. If the day was very uncharacteristic of your normal intake, then choose a day that is fairly recent and typical (not necessarily dietetically "good"!) of your normal eating habits. This gives me an idea of how your metabolism is coping with what you are eating presently. Think carefully through each meal, and what you may have snacked on in between. Please include details such as whether or not the milk you may have used was low fat or full cream; how many sugars you used on your cereal, and how a meal was made. Don't just say "grilled" - include for example, that you brushed the chicken with a little olive oil and herbs, and left the skin on, and that the chicken was the thigh - and that you had 2 pieces, for instance. Try and estimate the amounts in whatever way you can using, for instance, the size of a match box for a piece of cheese, or a "fistful" for a portion of mashed potato, etc. The more information I have, the better! Don't forget what you drank all the way through the day, as well as the 'treats' you may have forgotten about, and the drinks of tea, coffee and water etc.