Metabolic Assessment Form

Nameyour full name

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MaleFemale

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

1st Major Concerndetails

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2nd Major Concerndetails

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3rd Major Concerndetails

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5th Major Concerndetails

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Please select any items that applies.

1 being the least and 3 being the most/always.

Category 1

	1	2	3
Feeling that bowels do not empty completely
Lower abdominal pain relief 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
Do you use laxatives frequently

Category 2

	1	2	3
Excessive belching, burping or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits / vegetables; undigested foods found in stools

Please select any items that applies.

1 being the least and 3 being the most/always.

Category 3

	1	2	3
Stomach pain, burning or aching 1-4 hours after eating
Do you frequently use antacids
Feeling hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief from antacids, food, milk carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods chocolate, citrus, peppers, alcohol and caffeine

Category 4

	1	2	3
Roughage and fiber cause constipation
Indigestion and fullness lasts 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
Difficulty losing weight

Category 5

	1	2	3
Greasy or high fat foods cause distress
Lower bowel gas and or bloating several hours after eating
Bitter metallic taste in mouth, especially in morning
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

Please select any items that applies.

1 being the least and 3 being the most/always.

Category 6

	1	2	3
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep yourself going or started
Get lightheaded if meals are missed
Eating relieves fatigue
Feel shaky, jittery, tremors
Agitated, easily upset, nervous
Poor memory, forgetful
Blurred vision

Category 7

	1	2	3
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
Increased thirst & appetite
Difficulty losing weight

Category 9

	1	2	3
Cannot fall asleep
Perspire easily
Under high amounts of stress
Weight gain when under stress
Wake up tiered even after 6 or more hours of sleep
Excessive perspiration or perspiration with little or no activity

Please select any items that applies.

1 being the least and 3 being the most/always.

Category 10

	1	2	3
Tiered, sluggish
Feel cold- hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight gain even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression, lack of motivation
Morning headaches, wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face or genitals or excessive hair failing out
Dryness of skin and / or scalp
Mental sluggishness

Please select any items that applies.

1 being the least and 3 being the most/always.

Category 15 (Males Only)

	1	2	3
Decrease in libido
Decrease in spontaneous morning erections
Decrease in fullness of erections
Difficulty in maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decrease in physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past

Please select any items that applies.

1 being the least and 3 being the most/always.

Category 16 (Menstruating Females Only)

	1	2	3
Are you perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle, greater than 32 days
Shortened menstrual cycle, less than every 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 breakouts

Category 17 (Menopausal Female Only)

	1	2	3
How many years have you been menopausal?
Do you ever have uterine bleeding since menopause?
Hot flashes
Mental Fogginess
Disinterested in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness or itching

How many alcoholic beverages do you consume per week?drinks per week

How many times do you eat out per week?# of times you eat out per week

How many times a week do you eat fish?fish meals per week

How many caffeinated beverages do you consume per day?drinks per week

How many times a week do you work out?Number of workouts per week

How many times a week do you eat raw nuts or seeds?Seeds and Nuts per week

List the three worst foods you during the average week.3 worst foods eaten during the week

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List the three healthiest foods you eat during the average week3 healthiest foods eaten during the week

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Any other type of medication you are currently taking.Other medications you are currently taking

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	1	2	3
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

	1	2	3
Heart palpations
Inward trembling
Increased pulse even at rest
Nervousness and emotional
Insomnia
Night sweats
Difficulty gaining weight

	1	2	3
Urination difficulty or dribbling
Urination frequent
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night

	1	2	3
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms

	1	2	3
Increased sex drive
Tolerance to sugars reduced
“Splitting” type headaches

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