Confidential Metabolic Questionnaire

This is an in-depth questionnaire for patients that are experiencing metabolic symptoms that might require laboratory testing. Please complete the entire questionnaire to the best of your ability. If you need any assistance, don't hesitate to reach out to us.

	Never	Sometimes	Often	Always
Feeling that your 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 amounts of foul-smelling gas
Use laxatives

	Never	Sometimes	Often	Always
Unpredictable food reactions
Unpredictable abdominal swelling
Frequent bloating and distention after eating
Eating sugars and starches creates abdominal symptoms

	Never	Sometimes	Often	Always
Intolerance to smells
Intolerance to jewelry
Intolerance of shampoos, lotions, detergents
Multiple smell and chemical sensitivities
Skin outbreaks

	Never	Sometimes	Often	Always
Belching, burping, or bloating within 45 min of eating
Gas immediately following a meal
Food seems to sit heavy in your stomach, like a rock
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables; undigested food found in stools

	Never	Sometimes	Often	Always
Stomach pain, burning, or aching 1-4 hours after eating
Use of antacids
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

	Never	Sometimes	Often	Always
Fruits and vegetables (roughage & fiber) cause constipation
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 has undigested food, foul smelling, mucous-like, greasy, or is poorly-formed
Greasy or high-fat foods cause digestive stress
Lower bowel gas and/or bloating several hours after eating

	Never	Sometimes	Often	Always
Bitter metallic taste in mouth, especially in the morning
Unexplained itchy skin
Yellowish color to eyes
Stool color alternates from clay-colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or scalp
Gallbladder attacks/ stones
Burp fishy taste after consuming fish oils
Pain/ache between shoulder blades

	Never	Sometimes	Often	Always
Acne/unhealthy skin
All over sense of bloating/swelling (not just abdomen)
Bodily swelling for no reason
Hormone imbalances
Excessively foul smelling sweat/ body odor

	Never	Sometimes	Often	Always
Feeling light-headed, irritable, shaky, or headaches with 3-4 hours of no food
Irritable if meals are missed
Depend on caffeine to get started or keep going
Get light-headed if meals are missed
Eating relieves fatigue

	Never	Sometimes	Often	Always
You get sleepy, tired, or drowsy 15-30 minutes after eating
Eating sweets does not relieve sugar cravings
Must have sweets after meals
Waist girth is equal to or larger than hip girth
Frequent urination
Increased thirst or appetite
Difficulty losing weight
Numbness or tingling in toes or feet

	Never	Sometimes	Often	Always
Cannot stay asleep at night
Crave salt
Afternoon fatigue
Afternoon headaches
Dizzy or Lightheadedness when standing up quickly
Headaches with exertion

	Never	Sometimes	Often	Always
Cannot fall asleep
Perspire/Sweat easily
Weight gain under stress
Wake up tired even with >6 hours sleep
Excessive sweating with little or no activity

	Never	Sometimes	Often	Always
Swelling in angles or wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Inability to hold breath for long periods
Shallow, rapid breathing

	Never	Sometimes	Often	Always
Tired/Sluggish
Feel cold in hands, feet, or all over
Require excessive amounts of sleep to function properly
Increase in weight gain even with low-calorie diets
Gain weight easily
Difficult or infrequent bowel movements
Depression/Lack Motivation
Outer third of eyebrows thinning
Thinning of hair on scalp, face, genitals, or excessive hair loss
Dryness of skin and/or scalp
Mental sluggishness
Shoulder pain/ Stiffness

	Never	Sometimes	Often	Always
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight

	Never	Sometimes	Often	Always
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased sex drive
Splitting headaches

	Never	Sometimes	Often	Always
Incomplete urination or dribbling
Frequent urination
Pain inside of legs or heels
Decreased libido
Decreased number of spontaneous morning erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decrease physical stamina
Increase fat distribution around chest and hips
Sweating attacks
More emotional than in the past

	Never	Sometimes	Often	Always
Perimenopausal
Irregular menstrual cycle lengths
Menstrual cycle (>32 days)
Menstrual cycle (less than 24 days)
Pain an cramping during periods
Scanty period
Heavy period
Breast pain and swelling during period
Pelvic pain during period
Irritable and depressed during period
Acne
Facial hair growth
Difficulty or inability to achieve orgasm

	Never	Sometimes	Often	Always
Bleeding since menopause
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Vaginal pain, dryness, itching

Confidential Metabolic Questionnaire

The Following is Your Unique Identifier from Registration