Metabolic Assessment Form



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


PART II
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
0123

Lower abdominal pain relieved by passing stool or gas
0123

Alternating constipation and diarrhea
0123

Diarrhea
0123

Constipation
0123

Hard, dry, or small stool
0123

Coated tongue or “fuzzy” debris on tongue
0123

Pass large amount of foul-smelling gas
0123

More than 3 bowel movements daily
0123

Use laxatives frequently
0123

Category II

Increasing frequency of food reactions
0123

Unpredictable food reactions
0123

Aches, pains, and swelling throughout the body
0123

Unpredictable abdominal swelling
0123

Frequent bloating and distention after eating
0123

Abdominal intolerance to sugars and starches
0123

Category III

Intolerance to smells
0123

Intolerance to jewelry
0123

Intolerance to shampoo, lotion, detergents, etc
0123

Multiple smell and chemical sensitivities
0123

Constant skin outbreaks
0123

Category IV

Excessive belching, burping, or bloating
0123

Gas immediately following a meal
0123

Offensive breath
0123

Difficult bowel movements
0123

Sense of fullness during and after meals
0123

Difficulty digesting fruits and vegetables undigested food found in stools
0123

Category V

Stomach pain, burning, or aching 1-4 hours after eating
0123

Use of antacids
0123

Feel hungry an hour or two after eating
0123

Heartburn when lying down or bending forward
0123

Temporary relief by using antacids, food, milk, or carbonated beverages
0123

Digestive problems subside with rest and relaxation
0123

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
0123

 
Category VI

Roughage and fiber cause constipation
0123

Indigestion and fullness last 2-4 hours after eating
0123

Pain, tenderness, soreness on left side under rib cage
0123

Excessive passage of gas
0123

Category XI

Cannot stay asleep
0123

Crave salt
0123

Slow starter in the morning
0123

Afternoon fatigue
0123

Dizziness when standing up quickly
0123

Afternoon headaches
0123

Headaches with exertion or stress
0123

Weak nails
0123

Category XII

Cannot fall asleep
0123

Perspire easily
0123

Under a high amount of stress
0123

Weight gain when under stress
0123

Wake up tired even after 6 or more hours of sleep
0123

Excessive perspiration or perspiration with little or no activity
0123

Category XIII

Edema and swelling in ankles and wrists
0123

Muscle cramping
0123

Poor muscle endurance
0123

Frequent urination
0123

Frequent thirst
0123

Crave salt
0123

Abnormal sweating from minimal activity
0123

Alteration in bowel regularity
0123

Inability to hold breath for long periods
0123

Shallow, rapid breathing
0123

Category XIV

Tired/sluggish
0123

Feel cold―hands, feet, all over
0123

Require excessive amounts of sleep to function properly
0123

Increase in weight even with low-calorie diet
0123

Gain weight easily
0123

Difficult, infrequent bowel movements
0123

Depression/lack of motivation
0123

Morning headaches that wear off as the day progresses
0123

Outer third of eyebrow thins
0123

Thinning of hair on scalp, face, or genitals, or excessive hair loss
0123

Dryness of skin and/or scalp
0123

Mental sluggishness
0123

Category XV

Heart palpitations
0123

Inward trembling
0123

Increased pulse even at rest
0123

Nervous and emotional
0123

Insomnia
0123

Category VI (Cont.)

Nausea and/or vomiting
0123

Stool undigested, foul smelling, mucous like, greasy, or poorly formed
0123

Frequent urination
0123

Increased thirst and appetite
0123

Category VII

Greasy or high-fat foods cause distress
0123

Lower bowel gas and/or bloating several hours after eating
0123

Bitter metallic taste in mouth, especially in the morning
0123

Burpy, fishy taste after consuming fish oils
0123

Difficulty losing weight
0123

Unexplained itchy skin
0123

Yellowish cast to eyes
0123

Stool color alternates from clay colored to normal brown
0123

Reddened skin, especially palms
0123

Dry or flaky skin and/or hair
0123

History of gallbladder attacks or stones
0123

Have you had your gallbladder removed?
YesNo

Category VIII

Acne and unhealthy skin
0123

Excessive hair loss
0123

Overall sense of bloating
0123

Bodily swelling for no reason
0123

Hormone imbalances
0123

Weight gain
0123

Poor bowel function
0123

Excessively foul-smelling sweat
0123

Category IX

Crave sweets during the day
0123

Irritable if meals are missed
0123

Depend on coffee to keep going/get started
0123

Get light-headed if meals are missed
0123

Eating relieves fatigue
0123

Feel shaky, jittery, or have tremors
0123

Agitated, easily upset, nervous
0123

Poor memory/forgetful
0123

Blurred vision
0123

Category X

Fatigue after meals
0123

Crave sweets during the day
0123

Eating sweets does not relieve cravings for sugar
0123

Must have sweets after meals
0123

Waist girth is equal or larger than hip girth
0123

Frequent urination
0123

Increased thirst and appetite
0123

Difficulty losing weight
0123

Category XV (Cont.)

Night sweats
0123

Difficulty gaining weight
0123

Category XVI (Males Only)

Urination difficulty or dribbling
0123

Frequent urination
0123

Pain inside of legs or heels
0123

Feeling of incomplete bowel emptying
0123

Leg twitching at night
0123

Category XVII (Males Only)

Decreased libido
0123

Decreased number of spontaneous morning erections
0123

Decreased fullness of erections
0123

Difficulty maintaining morning erections
0123

Spells of mental fatigue
0123

Inability to concentrate
0123

Episodes of depression
0123

Muscle soreness
0123

Decreased physical stamina
0123

Unexplained weight gain
0123

Increase in fat distribution around chest and hips
0123

Sweating attacks
0123

More emotional than in the past
0123

Category XVIII (Menstruating Females Only)

Perimenopausal
YesNo

Alternating menstrual cycle lengths
YesNo

Extended menstrual cycle (greater than 32 days)
YesNo

Shortened menstrual cycle (less than 24 days)
YesNo

Pain and cramping during periods
0123

Scanty blood flow
0123

Heavy blood flow
0123

Breast pain and swelling during menses
0123

Pelvic pain during menses
0123

Irritable and depressed during menses
0123

Acne
0123

Facial hair growth
0123

Hair loss/thinning
0123

Category XIX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?
YesNo

Hot flashes
0123

Mental fogginess
0123

Disinterest in sex
0123

Mood swings
0123

Depression
0123

Painful intercourse
0123

Shrinking breasts
0123

Facial hair growth
0123

Acne
0123

Increased vaginal pain, dryness, or itching
0123

PART III

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