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Hormone Therapy
- - - Women
      Hormone Therapy for Women
      
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  - - Men
      Hormone Therapy for Men
      
      Testosterone Replacement Therapy
      
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Wellness Services
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Medical Weight Loss
Sexual Health
- - - Women
      Sexual Enhancement – Women
      
      Urinary Incontinence
      
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      Ultra Femme 360
      
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      Vaginal Dryness
      
      G-Shot
      
      O-Shot
  - - Men
      Sexual Enhancement – Men
      
      Erectile Dysfunction
      
      Shockwave Therapy for ED
      
      P-Shot
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Specials & Events
About Us

Hormone Therapy
- Women
- Men
Wellness Services
Aesthetics Services
Medical Weight Loss
Sexual Health
- Women
- Men
  - Sexual Enhancement – Men
  - Erectile Dysfunction
    - Shockwave Therapy for ED
    - P-Shot
Membership
Specials & Events
About Us

Hormone Therapy
- Women
- Men
Wellness Services
Aesthetics Services
Medical Weight Loss
Sexual Health
- Women
- Men
  - Sexual Enhancement – Men
  - Erectile Dysfunction
    - Shockwave Therapy for ED
    - P-Shot
Membership
Specials & Events
About Us

Women’s Consultation Form

Please be sure to fill in all information below. Blank boxes with an asterisk (*) will not submit successfully. Upon completion please click ‘Submit’ at the bottom of the screen. A confirmation screen will appear. If this screen does not appear, please correct the red boxes and click “Submit” once more.

Step 1 of 8

12%

Referred By(Required)

First Name(Required)

Last Name(Required)

Address(Required)

Street Address Address Line 2 City State Zip Code

Primary Phone Number(Required)

Backup Phone Number(Required)

Work Number(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Occupation(Required)

Marital Status(Required)

Date of Last Menstrual Period

MM slash DD slash YYYY

No. of pregnancies

No. of deliveries

Reasons for Visit

Please check all applicable(Required)

Excessive Weight

Chronic Fatigue Syndrome

Colitis

Diabetes

Elevated Cholesterol

Elevated Triglycerides

Heart Disease

Hypertension

Hypothyroidism

Irrit. Bowel Syndrome

Kidney Disease

Stroke

Health/Depression

Mitral Valve Prolapse

Chronic Yeast Infection

Seizures

Sleep Disorders

Skin Complaints

Check All

If reason is not listed please explain

Are you interested in our other services?

Health Maintenance (Date last done)

MMG

MM slash DD slash YYYY

Pap

MM slash DD slash YYYY

Lipid Profile

MM slash DD slash YYYY

Flex Sigmoidoscopy

MM slash DD slash YYYY

Name of Primary Care Physician

Number of Primary Care Physician

Pharmacy Name(Required)

Pharmacy Number(Required)

Pharmacy Zip Code(Required)

Medical Problems (Explained from above)

Current Medications or Supplements

Current Birth Control Method (if applicable)

Current Hormones Taken

Do you have any drug allergies?

Yes

No

If yes, give medication and reaction

Do you excercise?

Yes

No

If Yes, What Kind/How Often?

Do you Smoke?

Yes

No

If Yes, How Much/How Long?

Do you Drink?

Yes

No

If Yes, How Much/How Long?

Have you had a major illness/hospitalization/surgery?

Yes

No

If Yes, Explain

Family History (Medical Problem(s))

Father - Alive or deceased?

Age

Mother - Alive or deceased?

Age

Brother/Sister - Alive or deceased?

Age

Brother/Sister - Alive or deceased?

Age

Brother/Sister - Alive or deceased?

Age

Brother/Sister - Alive or deceased?

Age

Brother/Sister - Alive or deceased?

Age

Is there a family history of (Please check)

Colon Cancer

Breast Cancer

Ovarian Cancer

High Blood Pressure

Diabetes

Heart Disease

Other

Review Of Symptoms

Heart

Do you have chest pain or any palpitations?

Yes

No

How often?

For how many years?

Have you had it evaluated?

Yes

No

If yes, please describe

Gastrointestinal System

Do you have abdominal cramping, bloating, excessive belching or intestinal gas?

Yes

No

How many times / week?

Urinary Tract

Have you ever had bladder infections/kidney infections?

Yes

No

How many times / year?

Do you have burning upon urination?

Yes

No

Do you have increased frequency of urination?

Yes

No

Yeast/Skin Fungus

Have you ever had a vaginal yeast infection?

Yes

No

For how many years?

How many times?

Environmental Allergies

Do you have environmental allergies such as: pollen, mold, cat, or dog?

Yes

No

Have you had an allergy test performed?

Yes

No

If yes, date

MM slash DD slash YYYY

Please list allergies below

Thyroid

Have you been diagnosed with Low Thyroid Disorder?

Yes

No

Have you had an allergy test performed?

Yes

No

If yes, please explain

Did you ever take thyroid medication?

Yes

No

Name of medication / dose

Are you still taking this medication, if not, when did you quit?

Malaise / Fatigue

Do you feel like you should have more energy?

Yes

No

What is your average energy level on a scale of 0-10 with 10 meaning brimming with energy and 1 or 2 meaning the inability to get our of bed?

Hair Condition

Have you had significant hair loss?

Yes

No

Weight

Do you have difficulty loosing weight?

Yes

No

If yes, for how long?

Are you interested in medical weight loss?

Yes

No

If yes, how many pounds would you like to lose?

Mood

Do you ever feel discouraged, blue or depressed more than 10% of the time?

Yes

No

What percentage of time / for how many years?

Have you ever taken Anti-Depressants?

Yes

No

If yes, which one(s)?

Skin

Do you have dry skin?

Yes

No

If yes, for how long?

Sleep

Do you have trouble falling or staying asleep?

Yes

No

Do you have afternoon fatigue?

Yes

No

Menstrual History - Premenopausal Questionsm

Pregnancy

Date of last normal menstrual period?

MM slash DD slash YYYY

At what age did you enter puberty?

How many pregnancies?

How many live births?

Miscarriages?

Date of last child's birth?

MM slash DD slash YYYY

Your age then?

Did you have difficulty becoming pregnant?

Yes

No

Did you receive infertility treatment?

Yes

No

If yes, what kind?

Birth Control

Have you had Tubal Ligation?

Yes

No

If yes, when?

Are you currently using an IUD?

Yes

No

Have you ever taken Depo-Provera?

Yes

No

Have you ever taken birth control pills?

Yes

No

If yes, how long (years/months)?

Date you discontinued pills (if applicable)?

MM slash DD slash YYYY

Are you currently taking any female hormones (progesterone or estrogen)?

Yes

No

If yes, which ones and for how long?

Pap Smear

Have you had an abnormal Pap Smear?

Yes

No

If yes, when?

Was your most recent Pap Smear normal?

Yes

No

Date of last Pap Smear

MM slash DD slash YYYY

Menstrual Periods

Do your menstrual periods occur at the same time each month?

Yes

No

If no, what is the shortest number of days between periods?

What is the longest number of days between periods?

How long have your cycles been irregular (months/years)?

Where your menstrual cycles ever regular?

Yes

No

How many days do your periods last?

Are your periods heavier or lighter than they used to be?

Yes

No

If yes, when did they change? (ex: after the birth of my 2nd child)

Do you have menstrual bleeding that occurs between your periods?

Yes

No

If yes, how long has this occurred (months/years)?

Premenstrual Syndrome

Do you have breast tenderness prior to your period?

Yes

No

Do you have mood swings prior to your period?

Yes

No

Do you have weight gain prior to your period?

Yes

No

Do you crave sweets of bread products prior to your period?

Yes

No

Do you develop headaches (not migraine) products prior to your period?

Yes

No

Do you have menstrual cramps?

Yes

No

Do you experience hot flashes?

Yes

No

Do you experience night sweats?

Yes

No

Have any of the above symptoms ever caused you to miss work, school, or cause you to be unable to do daily functions?

Yes

No

Estrogen Dominance

Do you have fibrocystic breast disease?

Yes

No

If yes, how long (months/years)?

Have you ever had Endometriosis?

Yes

No

If yes, how long (months/years)?

Do you have uterine fibroids?

Yes

No

Have you developed any dark hair on your face?

Yes

No

If yes, how long ago did it begin (months/years)?

Have you developed any dark hair on your breasts?

Yes

No

If yes, how long ago did it begin (months/years)?

Have you had a decrease in sexual desire?

Yes

No

If yes, for how long?

Do you ever have pain or discomfort during or after intercourse?

Yes

No

Due to vaginal dryness?

Yes

No

If yes, for how long?

Bone Density

Have you ever been diagnosed with Osteoporosis?

Yes

No

Recurrent Medications

Do you currently take any prescription medications?

Yes

No

Please list the strength, time/day, and number of years taken for each:

Do you currently take any vitamins or supplements?

Yes

No

Please list the strength, time/day, and number of years taken for each:

Weight Loss Questionnaire

What are your weight loss goals?

What weight loss methods have you tried previously?

How much weight did you lose? Are you happy with the results?

Please list your food intake on a typical day: Include Time of Day, Food Eaten, and Total Calories for Each Meal - See more at:

Breakfast

Lunch

Dinner

Test Yourself Forms

Please fill out all of the Test Yourself forms below. Even if you are not concerned with these issues these are required for your visit with Dr. Shel.

Low Thyroid Function

This Thyroid Questionnaire lists symptoms and other factors most commonly found in people suffering from low thyroid, or hypothyroidism. Read each question carefully and check the symptom that applies to you.

Low Thyroid Function (Check all that apply)*(Required)

Do you have fatigue? Yes (4)

Do you have elevated cholesterol? Yes (4)

Do you have difficulty losing weight? Yes (2)

Do you have cold hands and feet? Yes (2)

Are you sensitive to the cold? Yes (2)

Do you have difficulty thinking? Yes (2)

Do you find it hard to concentrate? Yes (2)

Do you experience brain fog? Yes (2)

Do you have poor short term memory? Yes (2)

Do you have depressed moods? Yes (2)

Are you experiencing hair loss? Yes (2)

Do you have less than one bowel movement a day? Yes (2)

Do you have dry skin? Yes (2)

Does your skin itch in the winter? Yes (1)

Do you have fluid retention? Yes (2)

Do you have recurrent headaches? Yes (1)

Do you sleep restlessly? Yes (1)

Are you tired when you awaken? Yes (2)

Do you have afternoon fatigue? Yes (2)

Do you experience tingling or numbness in your hands or feet? Yes (2)

Do you have decreased sweating? Yes (2)

Have you had problems with infertility or miscarriages? Yes (2)

Do you have recurrent infections? Yes (2)

Do your muscles ache? Yes (2)

Do you have joint pain? Yes (2)

Do you have thinning of your eyebrows or eyelashes? Yes (2)

Is your tongue enlarged with teeth indentations? Yes (2)

Is your skin pasty, puffy or pale? Yes (2)

Do you have decreased body hair? Yes (2)

Is your voice hoarse? Yes (1)

Do you have a slow pulse? Yes (2)

Do you have low blood pressure? Yes (2)

Do your body temperature run below the normal 98.6 degrees? Yes (4)

Do you have sleep apnea? Yes (2)

None

Check All

< 9 | It is not likely that you have Low thyroid.
9-28 | Low thyroid is a possibility.
> 28 | Low thyroid is very likely.

Female Hormonal Imbalance

This questionnaire lists symptoms and other factors most commonly found in women who are either perimenopausal or menopausal, and suffering from low estrogen. Read each question carefully and check the symptom that applies to you.

Female Hormonal Imbalance (Check all that apply)(Required)

Do you have hot flashes? Yes (4)

Do you have night sweats? Yes (4)

Do you have vaginal dryness? Yes (3)

Do you urinate frequently? Yes (2)

Are you depressed? Yes (2)

Do you have difficulty sleeping? Yes (3)

Have you lost interest in sex? Yes (2)

Have your periods ceased? Yes(4)

None

Check All

< 5 | It is not likely that you have low estrogen.
5-9 | Low estrogen is a possibility.
> 9 | Low estrogen is very likely.

Estrogen Dominance

This Estrogen Dominance Questionnaire lists symptoms and other factors most commonly found in women suffering from Estrogen Dominance and/or Progesterone Deficiency. Read each question carefully and check the symptom that applies to you.

Estrogen Dominance (Check all that apply)(Required)

Do you have premenstrual breast tenderness? Yes (4)

Do you have premenstrual mood swings? Yes (4)

Do you have premenstrual fluid retention and weight gain? Yes (4)

Do you have premenstrual headaches? Yes (4)

Do you have migraine headaches? Yes (3)

Do you have severe menstrual cramps? Yes (3)

Do you have heavy periods with clotting? Yes (3)

Do you have irregular menstrual cycles? Yes (3)

Do you have uterine fibroids? Yes (3)

Do you have fibrocystic breast disease? Yes (3)

Do you have endometriosis? Yes (2)

Have you had problems with infertility? Yes (2)

Have you had more than one miscarriage? Yes (2)

Do you have joint pain? Yes (1)

Do you have muscle pain? Yes (1)

Do you have decreased libido? Yes (3)

Do you have anxiety or panic attacks? Yes (2)

None

Check All

< 5 | It is not likely that you have estrogen dominance.
5-8 | Estrogen dominance is a possibility.
9-20 | Estrogen dominance is probable.
> 20 | Estrogen dominance is very likely.

Low Testosterone

This questionnaire lists symptoms and other factors most commonly found in women suffering from low testosterone. Read each question carefully and check the symptom that applies to you.

Low Testosterone (Check all that apply)(Required)

Do you have fatigue? Yes (2)

Do you have lack of drive? Yes (3)

Do you lack initiative? Yes (3)

Are you less assertive? Yes (3)

Do you have a decline in your sense of well being? Yes (2)

Do you have depressed moods? Yes (2)

Are you frequently irritable? Yes (2)

Has your self-confidence declined? Yes (2)

Do you find it difficult to set goals? Yes (2)

Do you have a difficulty time making decisions? Yes (2)

Have you had a decline in your mental sharpness? Yes (2)

Has your stamina and endurance lessened? Yes (2)

Have you lost muscle mass, strength or tone? Yes (4)

Have you gained body fat around your waist? Yes (2)

Do you have elevated cholesterol? Yes (2)

Has your libido decreased? Yes (2)

Has your sexual ability declined? Yes (2)

None

Check All

< 7 | It is not likely that you have low testosterone.
7-20 | Low testosterone is a possibility.
> 20 | Low testosterone is very likely.

Yeast Overgrowth

This Yeast Questionnaire lists symptoms and other factors most commonly found in people suffering from Yeast Overgrowth. Read each question carefully and check the symptom that applies to you.

Yeast Overgrowth (Check all that apply)(Required)

Do you have fatigue? Yes (3)

Do you feel lethargic? Yes (2)

Do you have recurrent vaginal yeast infections? Yes (4)

Have you taken antibiotics multiple times during your life? Yes (3)

Do you abdominal bloating, cramping or gas? Yes (3)

Do you have indigestion or heartburn? Yes (2)

Do you have abnormal bodily reactions to wine, bear, or alcoholic beverages, such as flushing, headache, sinus congestion or itchy skin? Yes (2)

Do you crave sugar or bread products? Yes (2)

Do you have difficulty concentrating? Yes (1)

Do you have depressed moods? Yes (1)

Do you develop skin rashes or hives? Yes (2)

Do you have athlete's foot? Yes (4)

Do you have rectal itching? Yes (4)

Do you have fungal infections under the toenails or fingernails? Yes (3)

Do you have allergy symptoms? Yes (3)

Do you have recurrent respiratory infections? Yes (1)

Do you have joint pain? Yes (1)

Do you have muscle pain? Yes (1)

None

Check All

< 10 | It is not likely that you have yeast overgrowth.
10-16 | Yeast overgrowth is a possibility.
> 16 | Yeast overgrowth is very likely.

Adrenal Fatigue

This Adrenal Fatigue Questionnaire lists symptoms and other factors most commonly found in people suffering from adrenal fatigue. Read each question carefully and check the symptom that applies to you.

Adrenal Fatigue (Check all that apply)(Required)

Do you have fatigue? Yes (3)

Do you have allergies? Yes (3)

Do you have asthma? Yes (3)

Do you have recurrent infections? Yes (3)

Are you under severe emotional stress? Yes (3)

Do you suffer from chronic pain or physical stress? Yes (3)

Do you have low blood pressure? Yes (2)

Do you have a low pulse rate (less than 70 bpm with no exercise)? Yes (2)

When you rise quickly, do you feel as though you might pass out? Yes (2)

Do you have depressed moods? Yes (2)

Do you have joint pain? Yes (2)

Do you have muscle pain? Yes (2)

Do you have low libido? Yes (2)

Do you have hair loss? Yes (2)

Do you have anxiety attacks? Yes (2)

None

Check All

< 7 | It is not likely that you have adrenal fatigue.
7-12 | Adrenal fatigue is a possibility.
> 12 | Adrenal fatigue is very likely.

Allergies

This Allergy Questionnaire lists symptoms and other factors most commonly found in people suffering from some form of allergy. Check the symptom that applies to you

Allergies (Check all that apply)(Required)

Do you have fatigue? Yes (3)

Do you have frequent headaches? Yes (2)

Do you have sneezing, post nasal drainage or itching of the nose? Yes (4)

Do you have frequent colds? Yes (2)

Do you experience dizziness? Yes (4)

Do you get sinus infections every year? Yes (1)

Do your eyes itch, water, get red or swell? Yes (4)

Do you have recurrent ear infections? Yes (2)

Do you have asthma, wheezing, tightness in the chest or chronic cough? Yes (4)

Do you have skin problems such as eczema, skin rashes, itching or hives? Yes (3)

Do you have indigestion, bloating diarrhea or constipation? Yes (1)

Do your symptoms worsen doing a particular season, such as the spring and fall? Yes (4)

Do your symptoms change when you go indoors or outdoors? Yes (3)

Are your symptoms worse in parks or grassy areas? Yes (4)

Are your symptoms worse when going to bed, or in the morning upon arising? Yes (2)

Do you awaken in the middle of the night with congestion? Yes (2)

Are your symptoms worse when you come into contact with dust? Yes (4)

Are your symptoms worse around animals? Yes (2)

Do you have any blood relatives with allergies? Yes (2)

Do you have mood swings or feel depressed for no reason? Yes (1)

Do you have recurrent yeast infections, jock itch, Athlete's foot or toenail fungus? Yes (2)

Do you develop symptoms after eating or drinking certain foods? Yes (2)

Do you sometimes feel stimulated, hyperactive, or fatigued after meals? Yes (2)

Do you have dark circles under your eyes? Yes (2)

Do you have a crease across the bridge of your nose? Yes (2)

None

Check All

< 9 | It is not likely that you have allergies.
9-12 | Possibility of allergies.
13-30 | Allergies are probable.
> 30 | Allergies are very likely.

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1437 Hwy 6 Ste 100 Sugar Land, TX 77478

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