Metabolic Intake Form

Full Name

First NameLast Name

Pronouns:

E-mail

Birthdate

Date

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

Please fill out form to best of knowledge (do not overthink it).

1- Colon

Rows	Least/Never	Sometimes	Commonly	Most/Always
Feeling that bowels do not empty completely
Lower abdominal pain relieved 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
Use laxatives frequently

2- Intestinal Barrier

Rows	Least/Never	Sometimes	Commonly	Most/Always
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains, and swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distention after eating

3- Chemical Tolerance

Rows	Least/Never	Sometimes	Commonly	Most/Always
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc
Multiple smell and chemical sensitivities
Constant skin outbreaks

4- Stomach

Rows	Least/Never	Sometimes	Commonly	Most/Always
Excessive belching, burping, or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting proteins and meats; undigested food found in stools

5- Stomach- Hyper

Rows	Least/Never	Sometimes	Commonly	Most/Always
Stomach pain, burning, or aching 1-4 hours after eating
Use of antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids, food, milk, or carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

6- Pancreas

Rows	Least/Never	Sometimes	Commonly	Most/Always
Difficulty digesting roughage and fiber
Indigestion and fullness last 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, mucus like, greasy, or poorly formed
Frequent loss of appetite

7-Small Intestine

Rows	Least/Never	Sometimes	Commonly	Most/Always
Abdominal distention after consumption of fiber, starches, and sugar
Abdominal distention after certain probiotic or natural supplements
Decreased gastrointestinal motility, constipation
Increased gastrointestinal motility, diarrhea
Alternating constipation and diarrhea
Suspicion of nutritional malabsorption
Frequent use of antacid medication
Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?

8- Biliary

Rows	Least/Never	Sometimes	Commonly	Most/Always
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours after eating
Bitter metallic taste in mouth, especially in the morning
Burping and fishy taste after consuming fish oils
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?

9- Hepatic Detox

Rows	Least/Never	Sometimes	Commonly	Most/Always
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat

10- Sugar Metabolism

Rows	Least/Never	Sometimes	Commonly	Most/Always
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory, forgetful between meals
Blurred vision

11- Sugar Utilization

Rows	Least/Never	Sometimes	Commonly	Most/Always
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
Frequent urination
Increased thirst and appetite
Difficulty losing weight

12- Adrenal Hypo

Rows	Least/Never	Sometimes	Commonly	Most/Always
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

13- Adrenal Hyper

Rows	Least/Never	Sometimes	Commonly	Most/Always
Cannot fall asleep
Perspire easily
Under a high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little or no activity

14- Electrolyte and ph

Rows	Least/Never	Sometimes	Commonly	Most/Always
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing

15- Thyroid

Rows	Least/Never	Sometimes	Commonly	Most/Always
Tired/sluggish
Feel cold―hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face, or genitals, or excessive hair loss
Dryness of skin and/or scalp
Mental sluggishness

16- Thyroid Hyper

Rows	Least/Never	Sometimes	Commonly	Most/Always
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight

17- Prostate (Men Only)

Rows	Least/Never	Sometimes	Commonly	Most/Always
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night

18- Andropause (Men Only)

Rows	Least/Never	Sometimes	Commonly	Most/Always
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past

19- Menstruating Women

Rows	Least/Never	Sometimes	Commonly	Most/Always
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 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
Facial hair growth
Hair loss/thinning
Increased vaginal pain, dryness, or itching

How many caffeinated beverages do you consume per day?

How many alcoholic beverages do you consume per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Please list any medications you are taking:

Please list any natural supplements you are taking:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat out per week?

List any injuries, surgeries or major traumas:

Family History of Illness:

Is there anything else you want me to know?

Please send copies of any recent lab tests.

Metabolic Intake Form.