Women’s Consultation Form

Name: Dr. Shel Wellness & Aesthetic Center
Address: 1437 Highway 6 Suite 100, Sugar Land, Texas, 77478
Telephone: 281.313.7435

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.

Referred By*
First Name*
Last Name*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone Number*
Backup Phone Number
Work Number
Date of Birth*
MM slash DD slash YYYY
Age*
Occupation
Marital Status
Date of Last Menstrual Period
MM slash DD slash YYYY
No. of pregnancies
No. of deliveries
Reasons for Visit
Please check all applicable
- 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 and Number of Primary Care Physician
Pharmacy Name and Number*
Pharmacy Zip Code*
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
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
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)*
- 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)*
- 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)*
- 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)*
- 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)*
- 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)*
- 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)*
- 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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About Us

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Wellness

Aesthetics

About Us

Specials & Events

Wellness

Aesthetics

Women’s Consultation Form

Reasons for Visit

Health Maintenance (Date last done)

Family History (Medical Problem(s))

REVIEW OF SYMPTOMS

MENSTRUAL HISTORY - PREMENOPAUSAL QUESTIONSM

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

Female Hormonal Imbalance

Estrogen Dominance

Low Testosterone

Yeast Overgrowth

Adrenal Fatigue

Allergies

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