Metabolic Screening Questionairre
Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Full Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Head
*
Rows
Never or almost never(0)
Occasionally, not severe (1)
Occasionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Headaches
Faintness
Dizziness
Insomnia
Eyes
*
Rows
Never or almost never(0)
Occasionally, not severe (1)
Occasionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Watery or Itchy Eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Ears
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Itchy ears
Earaches ear infections
Drainage from Ear
Ringing in Ears
hearing loss
Nose
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Stuffy Nose
Sinus Problems
Hay Fever
Sneezing Attacks
Excessive Mucus Formation
Mouth/Throat
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Chronic Coughing
Gagging, frequent need to clear throat
Sore throat, horseness, loss of voice
Swollen or discolored gums, lips
Canker Sores
Skin
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Acne
Hives, Rashes, Dry Skin
Hair Loss
flushing, Hot Flashes
Excessive Sweating
Lungs
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Chest Congestion
Asthma, Bronchitis
Shortness of Breath
Difficulty Breathing
Digestive Tract
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Nausea, Vomitting
Diarrhea
Constipation
Bloated Feeling
Belching, passing gas
Heartburn
Intestinal Pain
Joints/Muscles
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Pain or aches in joints
Arthritis
Stiffiness
Pain or aches in muscles
Feeling of weakness or tiredness
Weight
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Binge eating/drinking
Craving Certain Foods
Excessive Weight
Compulsive Eating
Water Retention
Underweight
Energy/Activity
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Fatigue, Sluggishness
Apathy, Lethargy
Hyperactivity
Restlessness
Mind
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Poor Memory
confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stutturing or Stammering
Slurred Speech
Learning Disabilities
Emotions
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Other
*
Rows
Never or almost never (0)
Ocassionaly, not severe (1)
Ocassionally, severe (2)
Frequently, not severe (3)
Frequently Severe (4)
Frequent Illness
Frequent or urgent urination
Genital Itch or discharge
Are you in the state of Washington and interested in establishing care with Dr. Rinde?
*
Yes
No
Maybe
I am outside of Washington interested in telemed options.
Comments
Please submit this secure document
Clear Form
Print Form
Should be Empty: