Vreeland Metabolic Assessment Form

Name*

First NameLast Name

Email*

example@example.com

Age

Sex

MaleFemale

Date

PART I

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

1.

2.

3.

4.

5.

PART II

Please choose 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

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Lower abdominal pain relieved by passing stool or gas

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Alternating constipation and diarrhea

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Diarrhea

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Constipation

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Hard, dry, or small stool

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Coated tongue or “fuzzy” debris on tongue

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Pass large amount of foul-smelling gas

	0	1	2	3

0 is Least/Never, 3 is Most/Always

More than 3 bowel movements daily

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Use laxatives frequently

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY II

Increasing frequency of food reactions

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Unpredictable food reactions

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Aches, pains, and swelling throughout the body

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Unpredictable abdominal swelling

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Frequent bloating and distention after eating

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY III

Intolerance to smells

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Intolerance to jewelry

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Intolerance to shampoo, lotion, detergents, etc

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Multiple smell and chemical sensitivities

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Constant skin outbreaks

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY IV

Excessive belching, burping, or bloating

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Gas immediately following a meal

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Offensive breath

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Difficult bowel movements

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Sense of fullness during and after meals

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Difficulty digesting proteins and meats; undigested food found in stools

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY V

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

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Use of antacids

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Feel hungry an hour or two after eating

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Heartburn when lying down or bending forward

	0	1	2	3

0 is Least/Never, 3 is Most/Always

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

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Digestive problems subside with rest and relaxation

	0	1	2	3

0 is Least/Never, 3 is Most/Always

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

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY VI

Difficulty digesting roughage and fiber

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Indigestion and fullness last 2-4 hours after eating

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Pain, tenderness, soreness on left side under rib cage

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Excessive passage of gas

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Nausea and/or vomiting

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Stool undigested, foul smelling, mucus like, greasy, or poorly formed

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Frequent loss of appetite

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY VII

Abdominal distention after consumption of fiber, starches, and sugar

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Abdominal distention after certain probiotic or natural supplements

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Decreased gastrointestinal motility, constipation

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Increased gastrointestinal motility, diarrhea

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Alternating constipation and diarrhea

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Suspicion of nutritional malabsorption

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Frequent use of antacid medication

	0	1	2	3

0 is Least/Never, 3 is Most/Always

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

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Lower bowel gas and/or bloating several hours after eating

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Bitter metallic taste in mouth, especially in the morning

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Burpy, fishy taste after consuming fish oils

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Unexplained itchy skin

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Yellowish cast to eyes

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Stool color alternates from clay colored to normal brown

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Reddened skin, especially palms

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Dry or flaky skin and/or hair

	0	1	2	3

0 is Least/Never, 3 is Most/Always

History of gallbladder attacks or stones

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Have you had your gallbladder removed?

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY IX

Acne and unhealthy skin

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Excessive hair loss

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Overall sense of bloating

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Bodily swelling for no reason

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Hormone imbalances

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Weight gain

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Poor bowel function

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Excessively foul-smelling sweat

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY X

Crave sweets during the day

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Irritable if meals are missed

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Depend on coffee to keep going/get started

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Get light-headed if meals are missed

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Eating relieves fatigue

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Feel shaky, jittery, or have tremors

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Agitated, easily upset, nervous

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Poor memory, forgetful between meals

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Blurred vision

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XI

Fatigue after meals

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Crave sweets during the day

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Eating sweets does not relieve cravings for sugar

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Must have sweets after meals

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Waist girth is equal or larger than hip girth

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Frequent urination

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Increased thirst and appetite

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Difficulty losing weight

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Cannot stay asleep

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Crave salt

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Slow starter in the morning

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Afternoon fatigue

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Dizziness when standing up quickly

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Afternoon headaches

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Headaches with exertion or stress

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Weak nails

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XIII

Cannot fall asleep

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Perspire easily

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Under a high amount of stress

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Weight gain when under stress

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Wake up tired even after 6 or more hours of sleep

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Excessive perspiration or perspiration with little or no activity

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XIV

Edema and swelling in ankles and wrists

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Muscle cramping

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Poor muscle endurance

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Frequent urination

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Frequent thirst

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Crave salt

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Abnormal sweating from minimal activity

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Alteration in bowel regularity

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Inability to hold breath for long periods

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Shallow, rapid breathing

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XV

Tired/sluggish

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Feel cold―hands, feet, all over

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Require excessive amounts of sleep to function properly

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Increase in weight even with low-calorie diet

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Gain weight easily

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Difficult, infrequent bowel movements

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Depression/lack of motivation

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Morning headaches that wear off as the day progresses

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Outer third of eyebrow thins

	0	1	2	3

0 is Least/Never, 3 is Most/Always

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

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Dryness of skin and/or scalp

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Mental sluggishness

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XVI

Heart palpitations

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Inward trembling

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Increased pulse even at rest

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Nervous and emotional

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Insomnia

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Night sweats

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Difficulty gaining weight

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XVII (Males Only)

Urination difficulty or dribbling

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Frequent urination

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Pain inside of legs or heels

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Feeling of incomplete bowel emptying

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Leg twitching at night

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XVIII (Males Only)

Decreased libido

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Decreased number of spontaneous morning erections

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Decreased fullness of erections

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Difficulty maintaining morning erections

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Spells of mental fatigue

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Inability to concentrate

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Episodes of depression

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Muscle soreness

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Decreased physical stamina

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Unexplained weight gain

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Increase in fat distribution around chest and hips

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Sweating attacks

	0	1	2	3

0 is Least/Never, 3 is Most/Always

More emotional than in the past

	0	1	2	3

0 is Least/Never, 3 is Most/Always

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

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Scanty blood flow

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Heavy blood flow

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Breast pain and swelling during menses

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Pelvic pain during menses

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Irritable and depressed during menses

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Acne

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Facial hair growth

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Hair loss/thinning

	0	1	2	3

0 is Least/Never, 3 is Most/Always

CATEGORY XX (Menopausal Females Only)

How many years have you been menopausal?

Years

Since menopause, do you ever have uterine bleeding?

YesNo

Hot flashes

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Mental fogginess

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Disinterest in sex

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Mood swings

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Depression

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Painful intercourse

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Shrinking breasts

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Facial hair growth

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Acne

	0	1	2	3

0 is Least/Never, 3 is Most/Always

Increased vaginal pain, dryness, or itching

	0	1	2	3

0 is Least/Never, 3 is Most/Always

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per week?

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: