MSQ
Metabolic Stress Questionnaire
Name
*
First Name
Last Name
Who Is Your Coach?
*Leave Blank If You Don't Have One Yet
Instructions for filling out this PDF:
Please click on the box to the left of each symptom you experience. If you experienced any of the symptoms in the past 1-3 months, then you should mark It. If you are unsure of any items on the list, please ask us about them or leave them blank. As you are filling this form out, please be open and honest about your answers; telling us how you feel will help us to HELP YOU better.
What We're Assessing
We’re using this to assess: S: SLEEP - H: HUNGER - R: RECOVERY - E: ENERGY - D: DIGESTION - S: STRESS (SHREDS)
Disclaimer:
This form looks at underlying root cause issues and their symptoms. Without more advanced testing, we cannot confirm anything, and we will never diagnose diseases.This Form is to be used as a diagnostic tool to guide our decision-making process as we implement diet, lifestyle, and more advanced lab testing recommendations; this is also to assess to see if any labs are even necessary.
Have You Filled Out an MSQ before?
*
YES
NO
Sleep
Less than 4 hours / night
4-6 hours / night
6-8 hours / night
8+ hours / night
Food Sensitivity Symptoms
Muscle/Joint Pain
Eczema
Skin Rashes
Auto-Immune Symptoms
Headaches/Migraines
Brain Fog
Fibromyalgia
Acid Reflux
Water Retention
Mineral Imbalances
Dizziness (on a weekly basis)
Increased Sweating
High Blood Pressure
Heart Arrhythmia
Low Blood Pressure
Heart Palpitations
Lightheadedness (especially when standing from a lying or seated position)
Low Mood/Apathy
Skin Discoloration
Allergies/Asthma
Confirmed Exposure To Mold
Nail Discoloration (white spots)
Dental Amalgam Fillings
Epliepsy/Seizures
Gut Symptoms
Allergies (asthma)
Thrush Of The Mouth
Acne (cystic back/forehead)
GI Pain (Weekly)
UTIs
Bloating Upon Waking
Burping After Meals
Bloating Evening
Gas (2)
Bloating Night
Underweight (can’t gain weight)
Diarrhea or loose Stool
Blood in the stool (or dark/black stool)
Auto-Immune Issues
Constipation
Food in Stool
Imbalanced Organic Acid Symptoms
Memory Issues
ADD/ADHD
Mood Imbalances
Learning Issues/Focus
Poor Growth
Unexplained Health Issues
Difficulty Concentrating
Omega-3 to Omega-6 Imbalance
High Cholesterol
Dry, flaking Skin
High Triglycerides
Arthritis
Low HDL
Hormone Imbalances
PMS Symptoms
Vision issues
Inflammatory Diseases
You Eat Fatty Fish Less Than 5 Days a Week
Hypothyroidism Symptoms (Low Thyroid)
Trouble Sleeping
Hair loss in the outer third of the eyebrow
Extreme Tiredness or Fatigue
Frequent, Heavy Periods
Sensitivity to Cold Temperature
Hoarseness of Voice
Cold Hands
Weight Gain
Low Stamina
Hyperthyroidism Symptoms (Too High Thyroid)
Anxiety
Can't Gain Weight
Irritability or Moodiness
Missed or Light Menstrual Periods
Nervousness, Hyperactivity
Sensitivity to high temperatures
Hand trembling (shaking)
Adrenal Imbalances
Fatigue During Day
Water Retention
Low Libido
Weight Gain or Loss
Depression
PMS Symptoms
Frequent Illness (More Than 2-4 times a year)
Insomnia
Aging-related Issues (catabolism)
Seasonal Affective Disorder (SAD)
Signs of Heavy Metals
Skin Inflammation (red rash)
Sweating (increased)
Skin Pigmentation Abnormalities
Breathing Difficulty
Tingling in Extremities
Unexplained Illness
Nausea
Vomiting
Insulin Sensitivity
Tired After You Eat Carbs
Poor or No Pumps in the Gym
Low Appetite
Fasted Insulin Over 6 piu/m
Please list medications or supplements you are currently taking.
How long have you spent "trying to diet" with or without success
Please Select
1-2 Weeks
1-2 Months
6+ Months
1+ Years
How much weight did you lose (leave blank if zero)
Please Select
1-10 Pounds
15-20 Pounds
20-30 Pounds
30-40 Pounds
50+ Pounds
Muscular Function
Have you had any new injuries
New since your last MSQ? Or fill out all injuries from the past 6 months
Have you had any new Surgeries
New since your last MSQ? Or fill out all Surgeries from the past 6 months
Do you experience tension/discomfort in your neck/upper back region?
Never
1-3x per month
1-3x per week
Daily/Nearly daily
Do you experience tension/discomfort in your hip/low back region?
Never
1-3x per month
1-3x per week
Daily/Nearly daily
Do you experience tension/discomfort in your Knee(s)
Never
1-3x per month
1-3x per week
Daily/Nearly daily
Are you able to touch your toes while keeping your legs straight with relative ease?
Yes
No
Yes, but it's somewhat difficult
Yes, but it's very hard
Females Clients
If AFAB (assigned female at birth)
Female Basic Hormone Health
Do you experience weight fluctuations?
Do you experience skin breakouts?
Do you suffer from PMS symptoms?
Do you suffer from urinary tract infections?
Do you suffer from irregular periods?
Do you experience occasional headaches?
Do you suffer from mood swings?
Do you experience water retention?
Do you suffer from fatigue?
PCOS
Hair growth (chin, chest, etc)
Muffin top fat gain
Are you taking birth control?
YES
NO
Are you pregnant or breast-feeding?
YES
NO
Have you ever been pregnant?
YES
NO
(If you have been pregnant) Did you experience gestational diabetes?
YES
NO
Number of Pregnancies/children
Pregnancies: Vaginal delivery or c-section or both
Vaginal delivery
C-section
Do you have diastasis recti/abdominal separation?
N/A if you are unsure
Do you experience leakage?
Never
Sometimes
Often
Do you experience pelvic pain?
Never
Sometimes
Often
Male Clients
If AMAB (assigned male at birth)
Male Hormone Assessment (Males only)
Low Sex Drive
Breast fat growth (Gino)
Tired and not excitable
Poor recovery
Fluid retention (Ankles, wrists, or hands)
Poor Muscle tone/skinny fat
Submit
Should be Empty: