Patient Evaluation Form
Name:
*
First Name
Last Name
Date of Birth:
*
/
Month
/
Day
Year
Gender:
*
Male
Female
Email:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile:
*
Format: (000) 000-0000.
Work Phone:
*
Format: (000) 000-0000.
Employer:
*
# of hours worked per week:
*
Marital Status:
*
Please Select
Single
Married
Widowed
Divorced
Number of Children:
*
Spouse's Name:
First Name
Last Name
Emergency Contact:
*
First Name
Last Name
Emergency Contact's Phone:
*
Format: (000) 000-0000.
Reason for your visit:
*
How did you hear about us?
*
Back
Next
DIAGNOSTIC EVALUATION
Have you been diagnosed with Diabetes?
*
YES
NO
What diabetic medication(s) do you currently take?
Have you been diagnosed with Thyroid Disease/Disorder?
*
YES
NO
If yes, what thyroid medication(s) do you currently take?
Have you been diagnosed with Autoimmune Disease?
*
YES
NO
If yes, please explain Autoimmune Disease:
Do you currently have or ever had any issues with your digestion and/or bowel elimination?
*
YES
NO
If yes, please explain:
#
*
of bowel movements per
day / week
*
.
ADDITIONAL INFORMATION
Please list any additional medication(s) or supplement(s):
Number of hours of sleep per day:
*
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Next
METABOLIC ASSESSMENT FORM
Patient Name:
*
First Name
Last Name
Age:
*
Gender:
*
Male
Female
PART I
Please list up to (5) major health concerns, in order of importance:
PART II
Please rate your answers below:
*
Rows
Never
Sometimes
Very Often
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 or "fuzzy" debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently
*
Rows
Never
Sometimes
Very Often
Always
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains and swelling throughout the body
Unpredictable abdominal swelling
Abdominal intolerance to sugars & starches
Frequent bloating & distention after eating
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc.
Multiple smell and chemical sensitivities
Constant skin outbreaks
*
Rows
Never
Sometimes
Very Often
Always
Excessive belching, burping or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movement
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables; undigested food found in stools
Stomach pain, burning or aching 1-4 hours after eating
Use antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief using antacids, food, milk or carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy food, chocolate, citrus, peppers, alcohol and caffeine
*
Rows
Never
Sometimes
Very Often
Always
Roughage and 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 undigested, foul smelling, mucous like, greasy, or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty losing weight
*
Rows
Never
Sometimes
Very Often
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
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?
*
YES
NO
*
Rows
Never
Sometimes
Very Often
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
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going or get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery or have tremors
Agitated, easily upset or nervous
Poor memory/forgetful
Blurred vision
*
Rows
Never
Sometimes
Very Often
Always
Fatigue after meals
Crave sweets duting the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meal
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight
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
*
Rows
Never
Sometimes
Very Often
Always
Cannot fall asleep
Perspire easily
Under 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
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
*
Rows
Never
Sometimes
Very Often
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
*
Rows
Never
Sometimes
Very Often
Always
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
Increased sex drive
Tolerance to sugars reduced
"Splitting" type headaches
Female Questionnaire
Do you still have a menstual cycle?
*
Yes
No
Please answer the following:
*
Rows
Yes
No
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
Menstration Symptoms - Please rate the following:
*
Rows
Never
Sometimes
Very Often
Always
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
How many years have you been menopausal?
*
Since menopause, do you ever have uterine bleeding?
*
Yes
No
Menopause Symptoms - Please rate the following:
*
Rows
Never
Sometimes
Very Often
Always
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increase vaginal pain, dryness, or itching
Part III
Please answer the following:
*
Rows
Quantity
How many alcoholic beverages do you consume per week?
How many caffeinated beverages do you consume daily?
On a scale 1-10, rate your stress level for an average week:
How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you exercise per week?
How many times do you eat raw nuts or seeds per week?
List the (3) WORST foods you eat during the average week:
*
List the (3) HEALTHIEST foods you eat during the average week:
*
Please verify that you are human
*
Submit
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