Metabolic Assessment Form

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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 teh 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:
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
Nausea and/or vomiting: 0123
Stool undigested, foul smelling, mucus like,
greasy, or poorly formed: 0123
Frequent urination: 0123
Increased thirst and appetite: 0123

Category VII
Abdominal distention after consumption of
fiber, starches, and sugar: 0123
Abdominal distention after certain probiotic
or natural supplements: 0123
Abdominal distention after certain probiotic
or natural supplements: 0123
Raised gastrointestinal motility, diarrhea: 0123
Alternating constipation and diarrhea: 0123
Suspicion of nutritional malabsorption: 0123
Frequent use of antacid medication: 0123
Have you been diagnosed with Celiac Disease,
Irritable Bowel Syndrome, Diverticulosis/
Diverticulitis, or Leaky Gut Syndrome?: YesNo

Category VIII
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 IX
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 X
Crave sweets during the day: 0123
Irritable if meals are missed: 0123
Depend on coffee to keep going/get started: 0123
Eating relieves fatigue: 0123
Feel shaky, jittery, or have tremors: 0123
Agitated, easily upset, nervous: 0123
Poor memory forgetful: 0123
Blurred vision: 0123
Light headed if meals are missed: 0123

Category XI
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 XII
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 XIII
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 XIV
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 XV
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 XVI
Heart palpitations: 0123
Inward trembling: 0123
Increased pulse even at rest: 0123
Nervous and emotional: 0123
Insomnia: 0123
Night sweats: 0123
Difficulty gaining weight: 0123

Category XVII
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 XVIII (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 XIX (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 XX (Menopausal Females Only)
How many years have you been menopausal?: YesNo
Since menopause, do you ever have uterine bleeding?: 0123
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: