Intake Interview Form and Nutritional Assessment Questionnaire

This scorecard is like a check-engine light for your body.

By rating your symptoms, you’ll get a total score plus scores in six key areas:

• hormones
• immune system
• digestion
• detoxification
• energy production
• nervous system
• oxidative stress

It’s a simple way to see how your body is really doing and where hidden stress might be holding you back—so you can start moving toward better balance and more energy.

 

Instructions:

Rate each symptom based on how strongly you experience it right now.

Use the scale:
1 = Weak · 2 = Mild · 3 = Moderate · 4 = Strong · 5 = Severe.
Leave blank if it doesn’t apply.

 

✨ Tip: Don’t overthink your answers—go with your first instinct based on your recent experience.

Metabolic Chaos Scorecard Disclaimer & Consent
By submitting your responses, you are acknowledging and consenting to the following:

Purpose of the Scorecard

The Metabolic Chaos Scorecard is a self-assessment tool only.
Its purpose is to help you reflect on your current symptoms, lifestyle patterns, and potential areas of stress on your body.
This tool is for informational and educational purposes only and is not a medical test or diagnosis.
Important Notes

This scorecard does not replace medical care or advice from a qualified healthcare provider.
No specific outcomes, diagnoses, or treatment results are guaranteed.
If you have or suspect you have a medical condition, please consult with your physician or licensed healthcare provider.
Consent

By submitting your scorecard, you:

• Confirm you understand this is an educational self-assessment, not a medical service.
• Agree that participation is voluntary and for personal insight only.
• Consent to the collection of your responses for the purpose of providing your score and related educational follow-up.

Privacy

Your information will be handled with care and will not be shared or sold. It may be used to send you resources, updates, or recommendations related to your results.