Men’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 7

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Referred By(Required)

First Name(Required)

Last Name(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State Zip Code

Primary Phone Number(Required)

Backup Phone Number

Work Number

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Occupation

Marital Status

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

Sleep Disorders

Skin Complaints

Check All

If reason is not listed, please explain

Are you interested in our other services?

Nutritional testing

Allergy testing

Laser skin tightening

Laser rejuvenation

Laser hair removal

Laser hair regrowth

Weight loss

Cellulite reduction

Body contouring

Bio Identical hormones

Fat reduction

Gluten and food testing

Check All

Health Maintenance (Date last done)

Bone Density

MM slash DD slash YYYY

Physical Exam

MM slash DD slash YYYY

PSA

MM slash DD slash YYYY

Lipid Profile

MM slash DD slash YYYY

Flex Sigmoidoscopy

MM slash DD slash YYYY

Medical Problems (Explained from above)

Name of Primary Care Physician

Number of Primary Care Physician

Current Medications

Pharmacy Name(Required)

Pharmacy Number(Required)

Pharmacy Zip Code(Required)

Current Supplements

Do you have any drug allergies?

Yes

If yes, give medication and reaction

Do you exercise?

Yes

If Yes, What Kind/How Often?

Do you Smoke?

Yes

If Yes, What Kind/How Often?

Have you had a major illness/hospitalization/surgery?

Yes

If Yes, Explain

Family History (Medical Problem(s))

Father - Alive or deceased?

Age

Mother - Alive or deceased?

Age

Brother/Sister - Alive or deceased?

Age

Brothers/Sisters - Alive or deceased?

Age

Brothers/Sisters - Alive or deceased?

Age

Brothers/Sisters - Alive or deceased?

Age

Brothers/Sisters - Alive or deceased?

Age

Is there a family history of (Please check)

Colon Cancer

Lung Cancer

Prostate Cancer

High Blood Pressure

Diabetes

Heart Disease

Other

Check All

REVIEW OF SYMPTOMS

Heart

Do you ever feel your heart skip a beat?

Yes

Do you have chest pain?

Yes

How often?

For how many years?

Is the pain sharp/stabbing/dull/aching?

Yes

Does it radiate to your neck, back or shoulders?

Yes

How long does the pain last?

Do you feel like you are going to pass out?

Yes

Gastrointestinal System

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

Yes

How many times / year?

For how many years?

Urinary Tract

Do you have burning upon urination?

Yes

Do you have increased frequency of urination?

Yes

Do you have any unexplained skin rashes or itchy skin?

Yes

For how long has this occurred?

Do you know the cause of your rashes/itchy skin?

Thyroid

Have you been diagnosed with a thyroid disorder?

Yes

Year Diagnosed

Were you diagnosed with hyperthyroidism?

Yes

Did you ever take thyroid medication?

Yes

What year did you quit?

Name of medicine

Dose of medicine

Malaise / Fatigue

Do you feel like you should have more energy?

Yes

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?

How Long?

Hair Condition

Do you have coarse or fine hair?

Yes

For how many years?

Have you ever had significant hair loss?

Yes

How long?

Weight

Have you had significant weight gain?

Yes

How many pounds?

Since what year?

Do you have difficulty losing weight?

Yes

How long?

Are you interested in medical weight loss?

Yes

Mood

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

Yes

What percent of time?

For how many years?

Have you ever taken anti-depressants?

Yes

If yes, which one(s)?

Between what ages?

Skin

Do you have dry skin?

Yes

If yes, for how many years?

Sleep

Do you have insomnia or restless sleep?

Yes

Do you feel tired after a full night's sleep?

Yes

If yes, for how many years?

Do you have afternoon fatigue?

Yes

How many hours of sleep do you require?

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.

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)

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 slow pulse? Yes (2)

Do you have low blood pressure? Yes (2)

Does 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.

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.

Check all that apply(Required)

Do you have fatigue? Yes (2)

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 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.

Check all that apply(Required)

First Choice

Do you have fatigue? Yes (3)

Do you feel lethargic? Yes (2)

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

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

Do you have indigestion or heartburn? Yes (2)

Do you have abnormal bodily reactions to wine, beer 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 jock itch? 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.

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

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 when you go 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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Women

Men

Men’s Consultation Form

Reasons for Visit

Health Maintenance (Date last done)

Family History (Medical Problem(s))

REVIEW OF SYMPTOMS

Heart

Gastrointestinal System

Urinary Tract

Thyroid

Malaise / Fatigue

Hair Condition

Weight

Mood

Skin

Sleep

Weight Loss Questionnaire

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

Test Yourself Forms

Low Thyroid Function

Low Testosterone

Yeast Overgrowth

Adrenal Fatigue

Allergies

Get My FREE Ebook!

WELLNESS

RESOURCES

AESTHETICS

ABOUT US

Women

Men

Men’s Consultation Form

Reasons for Visit

Health Maintenance (Date last done)

Family History (Medical Problem(s))

REVIEW OF SYMPTOMS

Heart

Gastrointestinal System

Urinary Tract

Thyroid

Malaise / Fatigue

﻿Hair Condition

Weight

﻿Mood

﻿Skin

﻿Sleep

Weight Loss Questionnaire

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

Test Yourself Forms

Low Thyroid Function

Low Testosterone

Yeast Overgrowth

Adrenal Fatigue

Allergies

Get My FREE Ebook!

RESOURCES

ABOUT US

Hair Condition

Mood

Skin

Sleep