Metabolic Function Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

1. Do you have high stress levels in any area of your life?* This field is required.

YESNO

4

2. Do you have difficulty turning your mind off and relaxing?* This field is required.

YESNO

5

3. Do you have negative feelings or thoughts about yourself?* This field is required.

YESNO

6

4. Do you experience pronounced mood swings?* This field is required.

YESNO

7

5. Do you often feel depressed?* This field is required.

YESNO

8

6. Do you feel fatigued in the afternoon that is relieved by eating?* This field is required.

YESNO

9

7. Are you irritable or shaky before meals?* This field is required.

YESNO

10

8. Are you a slow starter in the morning?* This field is required.

YESNO

11

9. Do you suffer from overall low energy?* This field is required.

YESNO

12

10. Do you have difficulty losing weight?* This field is required.

YESNO

13

11. Are you over 10 lbs. heavier than your ideal body weight?* This field is required.

YESNO

14

12. Do you purposely avoid specific places or specific events because of your weight?* This field is required.

YESNO

15

13. Have you tried multiple diet plans and programs without success?* This field is required.

YESNO

16

14. If female, do you experience PMS, irregular menstrual cycles or are you in menopause?

YESNO

17

15. Do you often feel cold or chilled when others around you are fine?* This field is required.

YESNO

18

16. Do you have dry skin and/or hair?* This field is required.

YESNO

19

17. Do you experience brain fog, or an inability to concentrate or focus?* This field is required.

YESNO

20

18. Do you have sleep-related issues?* This field is required.

YESNO

21

19. Are you limited in what you can do physically due to your health issues?* This field is required.

YESNO

22

20. Do you have strong food cravings?* This field is required.

YESNO

23

Total Number of "Yes" answersIf you have answered "yes" to more than 5 of these questions it is likely that you are experiencing a gut/brain barrier impairment. A thorough functional evaluation is recommended.