Metabolic Assessment Form

Metabolic Assessment Form
Name
First NameLast Name
Email
example@example.com
Phone Number
Area CodePhone Number
Birth Date
MonthDayYear
Gender
Please list your 5 major health concerns in order of importance
Please tell us about any diagnostic tests you've had within the last year
Please tell us about any other therapies that you've tried for your current health concerns and the results
How many times do you work out per week?
How many caffeinated beverages do you consume per day?
How many alcoholic beverages do you consume per week?
How many cigarettes do you smoke per day?
How many times do you eat out per week?
Rate your stress level on a scale of 1 (lowest) to 10 (highest) during the average week?
How many times do you eat raw nuts and or seeds per week?
How many times do you eat fish per week?
Please list any medications you take and for what conditions.
Please list any natural supplements you take and for what conditions.
Feeling that bowels do not empty completely

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Lower abdominal pain relieved by passing stool or gas

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Alternating constipation and diarrhea

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Alternating constipation and diarrhea

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Coated tongue or "fuzzy" debris on tongue

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Pass large amount of foul smelling gas

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Excessive belching, burping, or bloating

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Offensive breath

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Sense of fullness during and after meals

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Difficulty digesting fruits and vegetables; undigested food found in stools

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Stomach pain, burning, or aching 1-4 hours after eating

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Feel hungry an hour or two after eating

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Temporary relief by using antacids, food, milk or carbonated beverages

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Digestive problems subside with rest and relaxation

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Pain, tenderness, soreness on left side under rib cage

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Stool undigested, foul smelling, mucous like, greasy, or poorly formed

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Frequent urination

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Increased thirst and appetite

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Lower bowel gas and/or bloating several hours after eating

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Bitter metallic taste in mouth, especially in the morning

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Stool color alternates from clay colored to normal brown

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
History of gallbladder attacks or stones

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Irritable if meals are missed

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Crave sweets during the day

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Depend on coffee to keep going/get started

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Feel shaky, jittery, or have tremors

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Agitated, easily upset, nervous

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Crave sweets during the day

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Eating sweets does not relieve cravings for sugar

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Waist girth is equal to or larger than hip girth

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Increased thirst and appetite

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Difficulty losing weight

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Cannot stay asleep

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Crave salt

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Dizziness when standing up quickly

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Headaches with exertion or stress

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Weight gain when under stress

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Wake up tired, even after 6 or more hours of sleep

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Excessive perspiration or perspiration with little or no activity

1 2 3 4 5
1 is Least/Never, 5 is Most/Always
Should be Empty: