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.

  • Reasons for Visit

  • Health Maintenance (Date last done)

  • Family History (Medical Problem(s))

  • REVIEW OF SYMPTOMS

    Heart
  • Gastrointestinal System
  • Urinary Tract
  • Yeast/Skin Fungus
  • Environmental Allergies
  • Thyroid
  • Malaise / Fatigue
  • Hair Condition
  • Weight
  • Mood
  • Skin
  • Sleep
  • MENSTRUAL HISTORY - PREMENOPAUSAL QUESTIONSM

    Pregnancy
  • Birth Control
  • Pap Smear
  • Menstrual Periods
  • Premenstrual Syndrome
  • Estrogen Dominance
  • Bone Density
  • Recurrent Medications
  • 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

    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.

  • < 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.

  • < 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.

  • < 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.

  • < 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.

  • < 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.

  • < 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

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