Metabolic Assessment

Metabolic Assessment Form
Full Name

First NameLast Name
Date

MonthDayYear
Person(s) filling out questionnaire

First NameLast Name
Age
Gender

MaleFemale
Phone Number

Area CodePhone 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

0123
Lower abdominal pain relieved by passing stool or gas

0123
Alternating constipation and diarrhea

0123
Diarrhea

0123
Constipation

0123
Hard, dry or small stool

0123
Coated tongue or "fuzzy" debris on tongue

0123
Pass large amounts of foul-smelling gas

0123
More than 3 bowel movements daily

0123
Use laxatives frequently

0123
Category II
Increasing frequency of food reactions

0123
Unpredictable food reactions

0123
Aches, pains, and swelling throughout the body

0123
Unpredictable abdominal swelling

0123
Frequent bloating and distention after eating

0123
Abdominal intolerance to sugars and starches

0123
Category III
Intolerance to smells

0123
Intolerance to jewelry

0123
Intolerance to shampoo, lotion, detergents, etc.

0123
Multiple smell and chemical sensitivities

0123
Constant skin outbreaks

0123
Category IV
Excessive belching, burping, or bloating

0123
Gas immediately following a meal

0123
Offensive breath

0123
Difficult bowel movements

0123
Sense of fullness during and after meals

0123
Difficulty digesting proteins and meats; undigested food found in stool

0123
Category V
Stomach pain, burning, or aching 1-4 hours after eating

0123
Use of antacids

0123
Feeling hungry an hour or two after eating

0123
Heartburn when lying down or bending forward

0123
Temporary relief by using antacids, food, milk, or carbonated beverages

0123
Digestive problems subside with rest and relaxation

0123
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

0123
Category VI
Difficulty digesting roughage and fiber

0123
Indigestion and fullness at least 2-4 hours after eating

0123
Pain, tenderness, soreness on left side under rib cage

0123
Excessive passage of gas

0123
Nausea and/or vomiting

0123
Stool indigested, foul smelling, mucus like, greasy, or poorly formed

0123
Frequent urination

0123
Increased thirst and appetite

0123
Frequent loss of appetite

0123
Category VII
Abdominal distention after consumption of fiber, starches, and sugar

0123
Abdominal distention after certain probiotic or natural supplements

0123
Decreased gastrointestinal motility, constipation

0123
Increased gastrointestinal motility, diarrhea

0123
Alternating constipation and diarrhea

0123
Suspicion of nutritional malabsorption

0123
Frequent use of antacid medication

0123
Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?

YesNo
Category VIII
Greasy or high-fat foods cause distress

0123
Lower bowel gas and/or bloating several hours after eating

0123
Bitter metallic taste in mouth, especially in the morning

0123
Burpy, fishy taste after consuming fish oils

0123
Difficulty losing weight

0123
Unexplained itchy skin

0123
Yellowish cast to eyes

0123
Stool color alternates from clay colored to normal brown

0123
Reddened skin, especially palms

0123
Dry or flaky skin and/or hair

0123
History of gallbladder attacks or stones

0123
Have you had your gallbladder removed?

YesNo
Category IX
Acne and unhealthy skin

0123
Excessive hair loss

0123
Overall sense of bloating

0123
Bodily swelling for no reason

0123
Hormone imbalances

0123
Weight gain

0123
Poor bowel function

0123
Excessively foul-smelling sweat

0123
Category X
Crave sweets during the day

0123
Irritable if meals are missed

0123
Depend on coffee to keep going/get started

0123
Get light-headed if meals are missed

0123
Eating relieves fatigue

0123
Feel shaky, jittery, or have tremors

0123
Agitated, easily upset, nervous

0123
Poor memory/forgetful between meals

0123
Blurred vision

0123
Category XI
Fatigue after meals

0123
Crave sweets during the day

0123
Eating sweets does not relieve cravings for sugar

0123
Must have sweets after meals

0123
Waist girth is equal or larger than hip girth

0123
Frequent urination

0123
Increased thirst and appetite

0123
Difficulty losing weight

0123
Category XII
Cannot stay asleep

0123
Crave salt

0123
Slow starter in the morning

0123
Afternoon fatigue

0123
Dizziness when standing up quickly

0123
Afternoon headaches

0123
Headaches with exertion or stress

0123
Weak nails

0123
Category XIII
Cannot fall asleep

0123
Perspire easily

0123
Under a high amount of stress

0123
Weight gain when under stress

0123
Wake up tired even after 6 or more hours of sleep

0123
Excessive perspiration, or perspiration with little or no activity

0123
Category XIV
Edema and swelling in ankles and wrists

0123
Muscle cramping

0123
Poor muscle endurance

0123
Frequent urination

0123
Frequent thirst

0123
Crave salt

0123
Abnormal sweating from minimal activity

0123
Alteration in bowel regularity

0123
Inability to hold breath for long periods

0123
Shallow, rapid breathing

0123
Category XV
Tired/sluggish

0123
Feel cold - hands, feet, all over

0123
Require excessive amounts of sleep to function properly

0123
Increase in weight even with low-calorie diet

0123
Gain weight easily

0123
Difficult, infrequent bowel movements

0123
Depression/lack of motivation

0123
Morning headaches that wear off as the day progresses

0123
Outer third of eyebrow thins

0123
Thinning of hair on scalp, face, or genitals, or excessive hair loss

0123
Dryness of skin and/or scalp

0123
Mental sluggishness

0123
Category XV
Heart palpitations

0123
Inward trembling

0123
Increased pulse even at rest

0123
Nervous and emotional

0123
Insomnia

0123
Night sweats

0123
Difficulty gaining weight

0123
Category XVII (Males Only)
Urination difficulty or dribbling

0123
Frequent urination

0123
Pain inside of legs or heels

0123
Feeling of incomplete bowel emptying

0123
Leg twitching at night

0123
Category XVIII (Males Only)
Decreased libido

0123
Decreased number of spontaneous morning erections

0123
Decreased fullness of erections

0123
Difficulty maintaining morning erections

0123
Spells of mental fatigue

0123
Inability to concentrate

0123
Episodes of depression

0123
Muscle soreness

0123
Decreased physical stamina

0123
Unexplained weight gain

0123
Increase in fat distribution around chest and hips

0123
Sweating attacks

0123
More emotional than in the past

0123
Category XIX (Menstruating Females Only)
Perimenopausal

YesNo
Alternating menstrual cycle lengths

YesNo
Extended menstrual cycle (greater than 32 days)

YesNo
Shortened menstrual cycle (less than 24 days)

YesNo
Pain and cramping during periods

0123
Scanty blood flow

0123
Heavy blood flow

0123
Breast pain and swelling during menses

0123
Pelvic pain during menses

0123
Irritable and depressed during menses

0123
Acne

0123
Facial hair growth

0123
Hair loss/thinning

0123
Category XX (Menopausal Females Only)
How many years have you been menopausal?
Since menopause, do you ever have uterine bleeding?

YesNo
Hot flashes

0123
Mental fogginess

0123
Disinterest in sex

0123
Mood swings

0123
Depression

0123
Painful intercourse

0123
Shrinking breasts

0123
Facial hair growth

0123
Acne

0123
Increased vaginal pain, dryness, or itching

0123
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)HexamethoniumArfonad®
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®THCCarbamate insecticidesEnlon®Prostigmin®Antilirium®Mestinon®
Cholinesterase Inhibitors (irreversible)

EchothiophateIsoflurophateOrganophosphate insecticidesOrganophosphate-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