Metabolic Assessment

Metabolic Assessment Form
Full Name

First Name Last Name
Date

Month Day Year
Person(s) filling out questionnaire

First Name Last Name
Age
Gender

Male Female
Phone Number

Area Code Phone Number
Email
example@example.com
Part 1 - Please list your five major health concerns in order of importance:
Part II Evaluation Directions: Please check the appropriate number on all questions below. 0 indicates least/never and 3 indicates most/always.
Category I
Feeling that bowels do not empty completely

0 1 2 3
Lower abdominal pain relieved by passing stool or gas

0 1 2 3
Alternating constipation and diarrhea

0 1 2 3
Diarrhea

0 1 2 3
Constipation

0 1 2 3
Hard, dry or small stool

0 1 2 3
Coated tongue or "fuzzy" debris on tongue

0 1 2 3
Pass large amounts of foul-smelling gas

0 1 2 3
More than 3 bowel movements daily

0 1 2 3
Use laxatives frequently

0 1 2 3
Category II
Increasing frequency of food reactions

0 1 2 3
Unpredictable food reactions

0 1 2 3
Aches, pains, and swelling throughout the body

0 1 2 3
Unpredictable abdominal swelling

0 1 2 3
Frequent bloating and distention after eating

0 1 2 3
Abdominal intolerance to sugars and starches

0 1 2 3
Category III
Intolerance to smells

0 1 2 3
Intolerance to jewelry

0 1 2 3
Intolerance to shampoo, lotion, detergents, etc.

0 1 2 3
Multiple smell and chemical sensitivities

0 1 2 3
Constant skin outbreaks

0 1 2 3
Category IV
Excessive belching, burping, or bloating

0 1 2 3
Gas immediately following a meal

0 1 2 3
Offensive breath

0 1 2 3
Difficult bowel movements

0 1 2 3
Sense of fullness during and after meals

0 1 2 3
Difficulty digesting proteins and meats; undigested food found in stool

0 1 2 3
Category V
Stomach pain, burning, or aching 1-4 hours after eating

0 1 2 3
Use of antacids

0 1 2 3
Feeling hungry an hour or two after eating

0 1 2 3
Heartburn when lying down or bending forward

0 1 2 3
Temporary relief by using antacids, food, milk, or carbonated beverages

0 1 2 3
Digestive problems subside with rest and relaxation

0 1 2 3
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

0 1 2 3
Category VI
Difficulty digesting roughage and fiber

0 1 2 3
Indigestion and fullness at least 2-4 hours after eating

0 1 2 3
Pain, tenderness, soreness on left side under rib cage

0 1 2 3
Excessive passage of gas

0 1 2 3
Nausea and/or vomiting

0 1 2 3
Stool indigested, foul smelling, mucus like, greasy, or poorly formed

0 1 2 3
Frequent urination

0 1 2 3
Increased thirst and appetite

0 1 2 3
Frequent loss of appetite

0 1 2 3
Category VII
Abdominal distention after consumption of fiber, starches, and sugar

0 1 2 3
Abdominal distention after certain probiotic or natural supplements

0 1 2 3
Decreased gastrointestinal motility, constipation

0 1 2 3
Increased gastrointestinal motility, diarrhea

0 1 2 3
Alternating constipation and diarrhea

0 1 2 3
Suspicion of nutritional malabsorption

0 1 2 3
Frequent use of antacid medication

0 1 2 3
Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?

Yes No
Category VIII
Greasy or high-fat foods cause distress

0 1 2 3
Lower bowel gas and/or bloating several hours after eating

0 1 2 3
Bitter metallic taste in mouth, especially in the morning

0 1 2 3
Burpy, fishy taste after consuming fish oils

0 1 2 3
Difficulty losing weight

0 1 2 3
Unexplained itchy skin

0 1 2 3
Yellowish cast to eyes

0 1 2 3
Stool color alternates from clay colored to normal brown

0 1 2 3
Reddened skin, especially palms

0 1 2 3
Dry or flaky skin and/or hair

0 1 2 3
History of gallbladder attacks or stones

0 1 2 3
Have you had your gallbladder removed?

Yes No
Category IX
Acne and unhealthy skin

0 1 2 3
Excessive hair loss

0 1 2 3
Overall sense of bloating

0 1 2 3
Bodily swelling for no reason

0 1 2 3
Hormone imbalances

0 1 2 3
Weight gain

0 1 2 3
Poor bowel function

0 1 2 3
Excessively foul-smelling sweat

0 1 2 3
Category X
Crave sweets during the day

0 1 2 3
Irritable if meals are missed

0 1 2 3
Depend on coffee to keep going/get started

0 1 2 3
Get light-headed if meals are missed

0 1 2 3
Eating relieves fatigue

0 1 2 3
Feel shaky, jittery, or have tremors

0 1 2 3
Agitated, easily upset, nervous

0 1 2 3
Poor memory/forgetful between meals

0 1 2 3
Blurred vision

0 1 2 3
Category XI
Fatigue after meals

0 1 2 3
Crave sweets during the day

0 1 2 3
Eating sweets does not relieve cravings for sugar

0 1 2 3
Must have sweets after meals

0 1 2 3
Waist girth is equal or larger than hip girth

0 1 2 3
Frequent urination

0 1 2 3
Increased thirst and appetite

0 1 2 3
Difficulty losing weight

0 1 2 3
Category XII
Cannot stay asleep

0 1 2 3
Crave salt

0 1 2 3
Slow starter in the morning

0 1 2 3
Afternoon fatigue

0 1 2 3
Dizziness when standing up quickly

0 1 2 3
Afternoon headaches

0 1 2 3
Headaches with exertion or stress

0 1 2 3
Weak nails

0 1 2 3
Category XIII
Cannot fall asleep

0 1 2 3
Perspire easily

0 1 2 3
Under a high amount of stress

0 1 2 3
Weight gain when under stress

0 1 2 3
Wake up tired even after 6 or more hours of sleep

0 1 2 3
Excessive perspiration, or perspiration with little or no activity

0 1 2 3
Category XIV
Edema and swelling in ankles and wrists

0 1 2 3
Muscle cramping

0 1 2 3
Poor muscle endurance

0 1 2 3
Frequent urination

0 1 2 3
Frequent thirst

0 1 2 3
Crave salt

0 1 2 3
Abnormal sweating from minimal activity

0 1 2 3
Alteration in bowel regularity

0 1 2 3
Inability to hold breath for long periods

0 1 2 3
Shallow, rapid breathing

0 1 2 3
Category XV
Tired/sluggish

0 1 2 3
Feel cold - hands, feet, all over

0 1 2 3
Require excessive amounts of sleep to function properly

0 1 2 3
Increase in weight even with low-calorie diet

0 1 2 3
Gain weight easily

0 1 2 3
Difficult, infrequent bowel movements

0 1 2 3
Depression/lack of motivation

0 1 2 3
Morning headaches that wear off as the day progresses

0 1 2 3
Outer third of eyebrow thins

0 1 2 3
Thinning of hair on scalp, face, or genitals, or excessive hair loss

0 1 2 3
Dryness of skin and/or scalp

0 1 2 3
Mental sluggishness

0 1 2 3
Category XV
Heart palpitations

0 1 2 3
Inward trembling

0 1 2 3
Increased pulse even at rest

0 1 2 3
Nervous and emotional

0 1 2 3
Insomnia

0 1 2 3
Night sweats

0 1 2 3
Difficulty gaining weight

0 1 2 3
Category XVII (Males Only)
Urination difficulty or dribbling

0 1 2 3
Frequent urination

0 1 2 3
Pain inside of legs or heels

0 1 2 3
Feeling of incomplete bowel emptying

0 1 2 3
Leg twitching at night

0 1 2 3
Category XVIII (Males Only)
Decreased libido

0 1 2 3
Decreased number of spontaneous morning erections

0 1 2 3
Decreased fullness of erections

0 1 2 3
Difficulty maintaining morning erections

0 1 2 3
Spells of mental fatigue

0 1 2 3
Inability to concentrate

0 1 2 3
Episodes of depression

0 1 2 3
Muscle soreness

0 1 2 3
Decreased physical stamina

0 1 2 3
Unexplained weight gain

0 1 2 3
Increase in fat distribution around chest and hips

0 1 2 3
Sweating attacks

0 1 2 3
More emotional than in the past

0 1 2 3
Category XIX (Menstruating Females Only)
Perimenopausal

Yes No
Alternating menstrual cycle lengths

Yes No
Extended menstrual cycle (greater than 32 days)

Yes No
Shortened menstrual cycle (less than 24 days)

Yes No
Pain and cramping during periods

0 1 2 3
Scanty blood flow

0 1 2 3
Heavy blood flow

0 1 2 3
Breast pain and swelling during menses

0 1 2 3
Pelvic pain during menses

0 1 2 3
Irritable and depressed during menses

0 1 2 3
Acne

0 1 2 3
Facial hair growth

0 1 2 3
Hair loss/thinning

0 1 2 3
Category XX (Menopausal Females Only)
How many years have you been menopausal?
Since menopause, do you ever have uterine bleeding?

Yes No
Hot flashes

0 1 2 3
Mental fogginess

0 1 2 3
Disinterest in sex

0 1 2 3
Mood swings

0 1 2 3
Depression

0 1 2 3
Painful intercourse

0 1 2 3
Shrinking breasts

0 1 2 3
Facial hair growth

0 1 2 3
Acne

0 1 2 3
Increased vaginal pain, dryness, or itching

0 1 2 3
Part III
How many alcoholic beverages do you consume per week?
Rate your level of stress during the average week on a scale of 1-10
How many caffeinated beverages do you consume per day?
How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work out per week?
How many times do you eat raw nuts or seeds per week?
List the three worst foods you eat during the average week:
List the three healthiest foods you eat during the average week:
Part IV
Please list any medications you currently take and for what conditions:
Medication
Dosage
Time of day and frequency per day
Condition
Medication
Dosage
Time of day and frequency per day
Condition
Medication
Dosage
Time of day and frequency per day
Condition
Medication
Dosage
Time of day and frequency per day
Condition
Medication
Dosage
Time of day and frequency per day
Condition
Medication
Dosage
Time of day and frequency per day
Condition
Medication
Dosage
Time of day and frequency per day
Condition
Medication
Dosage
Time of day and frequency per day
Condition
Please list any natural supplements you currently take and for what conditions:
Supplement
Dosage
Time of day and frequency per day
Condition
Supplement
Dosage
Time of day and frequency per day
Condition
Supplement
Dosage
Time of day and frequency per day
Condition
Supplement
Dosage
Time of day and frequency per day
Condition
Supplement
Dosage
Time of day and frequency per day
Condition
Supplement
Dosage
Time of day and frequency per day
Condition
Medication History

Please check any of the following medications you have taken in the past or are currently taking.
Noradrenergic and Specific Serotonergic Antidepressants (NaSSAs)

Remeron® Zispin® Avanza® Norset® Remergil® Axit®
Tricyclic Antidepressants (TCAs)

Elavil® Endep® Tryptanol® Trepiline® Asendin® Asendis® Defanyl® Demolox® Moxadil® Anafranil® Norpramin® Pertofrane® Thaden™ Prothiaden® Adapin® Sinequan® Tofranil® Janamine® Gamanil® Aventyl® Pamelor® Opipramol® Vivactil® Rhotrimine® Surmontil® Norpramin®
Selective Serotonin Reuptake Inhibitors (SSRIs)

Paxil® Zoloft® Prozac® Celexa® Lexapro® Esertia® Luvox® Cipramil® Emocal® Seropram® Cipralex® Fontex® Priligy® Seromex® Seronil® Sarafem® Fluctin® Faverin® Seroxat® Aropax® Deroxat® Rexetin® Paroxat® Lustral® Serlain®
Sertonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Effexor® Pristiq® Meridia® Serzone® Dalcipran® Cymbalta®
Selective Serotonin Reuptake Enhancers (SSREs)

Stablon® Coaxil® Tatinol®
Monoamine Oxidase Inhibitors (MAOIs)

Marplan® Aurorix® Manerix® Moclodura® Nardil® Adeline® Eldepryl® Azilect® Marsilid® Iprozid® Ipronid® Rivivol® Propilniazida® Zyvox® Zyvoxid®
Dopamine Receptor Agonists

Mirapex® Sifrol® Requip®
Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)

Wellbutrin XL®
D2 Dopamine Receptor Blockers (antipsychotics)

Thorazine® Prolixin® Trilafon® Compazine® Mellaril® Stelazine® Vesprin® Nozinan® Depixol® Navane® Fluanxol® Clopixol® Acuphase® Haldol® Orap® Clozaril® Zyprexa® Zydis® Seroquel XR® Geodon® Solian® Invega® Abilify®
GABA Antagonist Competitive Binder

Romazicon®
Agonist Modulators of GABA Receptors (benzodiazepines)

Xanax® Leotanil® Lexotan® Librium® Klonopin® Valium® Prosom® Rohypnol® Magadon® Dalmane® Ativan® Loramet® Sedoxil® Dormicum® Serax® Restoril® Halcion®
Agonist Modulators of GABA Receptors (non-benzodiazepines)

Ambien CR® Sonata® Lunesta® Imovane®
Acetylcholine Receptor Agonists

Urecholine® Evoxac® Salagen® Isopto® Nicotone
Acetylcholine Receptor Antagonists (antimuscarinic agents)

AtroPen® Scopace® Atrovent® Spiriva®
Acetylcholine Receptor Antagonists (ganglionic blockers)

Inversine® Nicotine (high doses) Hexamethonium Arfonad®
Acetylcholine Receptor Antagonists (neuromuscular blockers)

Tracrium® Nimbex® Nuromax® Metubine® Mivacron® Pavulon® Zemuron® Anectine® Tubocurarine® Norcuron® Hemicholinium-3®
Acetylcholinesterase Reactivators

Protopam®
Cholinesterase Inhibitors (reversible)

Aricept® Razadyne® Exelon® Cognex® THC Carbamate insecticides Enlon® Prostigmin® Antilirium® Mestinon®
Cholinesterase Inhibitors (irreversible)

Echothiophate Isoflurophate Organophosphate insecticides Organophosphate-containing nerve agents
*Please refer to prescribing physician for nutritional interactions with any medications you are taking.
Should be Empty:

Metabolic Assessment Form

Category I

Category II

Category III

Category IV

Category V

Category VI

Category VII

Category VIII

Category IX

Category X

Category XI

Category XII

Category XIII

Category XIV

Category XV

Category XV

Category XVII (Males Only)

Category XVIII (Males Only)

Category XIX (Menstruating Females Only)

Category XX (Menopausal Females Only)

Part III

Part IV

Medication History