Metabolic Assessment Form

BASIC INFORMATION

Name *

First

Last

Email *

Age *

Sex *

PART 1

Please list your 5 major health concerns in order of importance: *

PART 2

* Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas *

Alternating constipation and diarrhea *

Diarrhea *

Constipation *

Hard, dry, or small stool *

Coated tongue or “fuzzy” debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category 2

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body *

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Abdominal intolerance to sugars and starches *

Category 3

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc. *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category 4

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movement *

Sense of fullness during and after meals *

Difficulty digesting fruits and vegetables; undigested food found in stools *

Category 5

Stomach pain, burning, or aching 1-4 hours after eating *

Use antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward *

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation *

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category 6

Roughage and fiber cause constipation *

Indigestion and fullness last 2-4 hours after eating *

Pain, tenderness, soreness on left side under rib cage *

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucous like, greasy, or poorly formed *

Frequent urination *

Increased thirst and appetite *

Category 7

Greasy or high-fat foods cause distress *

Lower bowel gas and/or bloating several hours after eating *

Bitter metallic taste in mouth, especially in the morning *

Burpy, fishy taste after consuming fish oils *

Difficulty losing weight *

Unexplained itchy skin *

Yellowish cast to eyes *

Stool color alternates from clay colored to normal brown *

Reddened skin, especially palms *

Dry or flaky skin and/or hair *

History of gallbladder attacks or stones *

Have you had your gallbladder removed? *

Category 8

Acne and unhealthy skin *

Excessive hair loss *

Overall sense of bloating *

Bodily swelling for no reason *

Hormone imbalances *

Weight gain *

Poor bowel function *

Excessively foul-smelling sweat *

Category 9

Crave sweets during the day *

Irritable if meals are missed *

Depend on coffee to keep going/get started *

Get light-headed if meals are missed *

Eating relieves fatigue *

Feel shaky, jittery, or have tremors *

Agitated, easily upset, nervous *

Poor memory/forgetful *

Blurred vision *

Category 10

Fatigue after meals *

Crave sweets during the day *

Eating sweets does not relieve cravings for sugar *

Must have sweets after meals *

Waist girth is equal or larger than hip girth *

Frequent urination *

Increased thirst and appetite *

Difficulty losing weight *

Category 11

Cannot stay asleep *

Crave salt *

Slow starter in the morning *

Afternoon fatigue *

Dizziness when standing up quickly *

Afternoon headaches *

Headaches with exertion or stress *

Weak nails *

Category 12

Cannot fall asleep *

Perspire easily *

Under high amount of stress *

Weight gain when under stress *

Wake up tired even after 6 or more hours of sleep *

Excessive perspiration or perspiration with little or no activity *

Category 13

Edema and swelling in ankles and wrists *

Muscle cramping *

Poor muscle endurance *

Frequent urination *

Frequent thirst *

Crave salt *

Abnormal sweating from minimal activity *

Alteration in bowel regularity *

Inability to hold breath for long periods *

Shallow, rapid breathing *

Category 14

Tired/sluggish *

Feel cold―hands, feet, all over *

Require excessive amounts of sleep to function properly *

Increase in weight even with low-calorie diet *

Gain weight easily *

Difficult, infrequent bowel movements *

Depression/lack of motivation *

Morning headaches that wear off as the day progresses *

Outer third of eyebrow thins *

Thinning of hair on scalp, face, or genitals, or excessive hair loss *

Dryness of skin and/or scalp *

Mental sluggishness *

Category 15

Heart palpitations *

Inward trembling *

Increased pulse even at rest *

Nervous and emotional *

Insomnia *

Night sweats *

Difficulty gaining weight *

Category 16

Diminished sex drive *

Menstrual disorders or lack of menstruation *

Increased ability to eat sugars without symptoms *

Category 17

Increased sex drive *

Tolerance to sugars reduced *

“Splitting” - type headaches *

Category 18 (Males Only)

Urination difficulty or dribbling

Frequent urination

Pain inside of legs or heels

Feeling of incomplete bowel emptying

Leg twitching at night

Category 19 (Males Only)

Decreased libido

Decreased number of spontaneous morning erections

Decreased fullness of erections

Difficulty maintaining morning erections

Spells of mental fatigue

Inability to concentrate

Episodes of depression

Muscle soreness

Decreased physical stamina

Unexplained weight gain

Increase in fat distribution around chest and hips

Sweating attacks

More emotional than in the past

Category 20 (Menstruating Females Only)

Perimenopausal

Alternating menstrual cycle lengths

Extended menstrual cycle (greater than 32 days)

Shortened menstrual cycle (less than 24 days)

Pain and cramping during periods

Scanty blood flow

Heavy blood flow

Breast pain and swelling during menses

Pelvic pain during menses

Irritable and depressed during menses

Acne

Facial hair growth

Hair loss/thinning

Category 21 (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?

Hot flashes

Mental fogginess

Disinterest in sex

Mood swings

Depression

Painful intercourse

Shrinking breasts

Facial hair growth

Acne

Increased vaginal pain, dryness, or itching

Part 3

How many alcoholic beverages do you consume per week? *

How many caffeinated beverages do you consume per day? *

How many times do you eat out per week? *

How many times do you eat raw nuts or seeds per week? *

Rate your stress level on a scale of 1-10 during the average week: *

How many times do you eat fish per week? *

How many times do you work out per week? *

List the three worst foods you eat during the average week: *

List the three healthiest foods you eat during the average week: *

Part 4

Please list any medications you currently take and for what conditions: *

Please list any natural supplements you currently take and for what conditions: *