METABOLIC ASSESSMENT FORM
NAME
AGE
SEX
Date
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Month
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Day
Year
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List 5 Major health concerns
Category 1
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Feeling bowels do not empty completely
Lower abdominal pain relieved by passing gas or stool
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard, dry, or small stool
Coated tongue or "fuzzy" debris on tongue
Pass large amount of foul smelling gas
More than 3 bowel movement daily
Use laxatives frequently
Category 2
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Increasing frequency of food reactions
Unpredictable food reactions
Aches,pains,swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distension after eating
Abdominal intolerance to sugars and starches
Category 3
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo,lotions,detergents,etc
Multiple smell and chemical sensitivities
Constant skin outbreaks
Category 4
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it 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
Category 5
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Stomach pain, burning, or aching 1-4 hours after eating
Use antacids
Feel hungry an hour or two after eating
Heartburn when laying down or bending forward
Temporary relief by using antacids, food,milk or carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate,citrus,peppers,alcohol and caffeine
Category 6
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours after eating
Pain.tenderness soreness on left side under ribcage
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, fouls smelling, mucus like, greasy or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty loosing weight
Category 7
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Greasy or high-fat foods cause distress
lower bowel gas and/or bloating several hours after eating
Bitter metalicl 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 or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed
Category 8
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel movement
Excessive foul-smelling sweat
Category 9
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremores
Agitated,easily upset, nervous
Poor memory/forgetful
Blurred vision
Category 10
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst or appettite
Difficulty loosing weight
Category 11
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
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
Category 12
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Cannot fall asleep
Perspire easily
Under high amount of stress
Weight gain under stress
Wake up titrd even after 6 hours or more of sleep
Excessive perspiration or perspiration with little or no activity
Category 13
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing
Category 14
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Tired/Slugish
Feel cold- hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight gain 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 odfskin and/or scalp
Mental sluggishness
Category 15
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight
Category 16
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Diminish sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
Category 17
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Increased sex drive
Tolerance to sugars reduced
"Splitting " type headaches
Category 18 MALES ONLY
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night
Category 19 MALES ONLY
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increased in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
Category 19 MENSTRUATING FEMALES ONLY
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Perimenopausal
Alternating menstrual cycle lenghts
Extended menstrual cycles (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
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
Category 20 MENOPAUSAL FEMALES ONLY
Rows
Never had
Had it but dont' have it now
Have it sometimes
Have it always
Hot Flashes
Mental foginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness or itching
How many years have you been Menopausal
Since Menopause, do you ever have uterine bleeding?
YES
NO
How many alcoholic beverages do you consume aper week
Rate your stress level on a scale 1-10 during the average week
How many caffeinated beverages do you consume a day
How many times do you eat out per week
How many times do you eat fish per week
How many times do you eat raw nuts or seeds per week
How many times do you work out per week
List the three worst foods you eat during the average week
List the three healthiest foods you eat during the average week
Please list any medications you currently take and for what condition
Please list any supplements you currently take and for what condition
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