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Section 1 of 1
  Metabolic Assessment Form  
Please Be Honest & Fill Out Completely
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Age
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Date
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Sex
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  Please list your 5 major health concerns in order of importance
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Please check the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
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Category I
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  Feeling that bowels do not empty completely  
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0
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Lower abdominal pain relieved by passing stool or gas
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Alternating constipation and diarrhea
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Diarrhea
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Option 5
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Constipation
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Hard, dry, or small stool
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Coated tongue or “fuzzy” debris on tongue
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Pass large amount of foul-smelling gas
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More than 3 bowel movements daily
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Use laxatives frequently
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Category 2
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Increasing frequency of food reactions
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Unpredictable food reactions
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Aches, pains, and swelling throughout the body
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Unpredictable abdominal swelling
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Frequent bloating and distention after eating
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Category 3
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Intolerance to smells
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Intolerance to jewelry
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Intolerance to shampoo, lotion, detergents, etc
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Intolerance to shampoo, lotion, detergents, etc
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Multiple smell and chemical sensitivities
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Constant skin outbreaks
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Category 4
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Excessive belching, burping, or bloating
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Gas immediately following a meal
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Offensive breath
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Difficult bowel movements
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Sense of fullness during and after meals
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Difficulty digesting proteins and meats; undigested food found in stools
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Category 5
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Stomach pain, burning, or aching 1-4 hours after eating
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Use of antacids
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Feel hungry an hour or two after eating
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Heartburn when lying down or bending forward
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Temporary relief by using antacids, food, milk, or carbonated beverages
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Digestive problems subside with rest and relaxation
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Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
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Category 6
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Difficulty digesting roughage and fiber
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Indigestion and fullness last 2-4 hours after eating
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Pain, tenderness, soreness on left side under rib cage
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Excessive passage of gas
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Nausea and/or vomiting
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Stool undigested, foul smelling, mucus like, greasy, or poorly formed
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Frequent loss of appetite
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Category 7
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Abdominal distention after consumption of fiber, starches, and sugar
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Abdominal distention after certain probiotic or natural supplements
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Decreased gastrointestinal motility, constipation
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Increased gastrointestinal motility, diarrhea
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Alternating constipation and diarrhea
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Suspicion of nutritional malabsorption
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Frequent use of antacid medication
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Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?
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NO
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Category 8
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Greasy or high-fat foods cause distress
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Lower bowel gas and/or bloating several hours after eating
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Bitter metallic taste in mouth, especially in the morning
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Burpy, fishy taste after consuming fish oils
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Unexplained itchy skin
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Yellowish cast to eyes
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Stool color alternates from clay colored to normal brown
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Reddened skin, especially palms
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Dry or flaky skin and/or hair
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History of gallbladder attacks or stones
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Have you had your gallbladder removed?
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NO
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Category 9
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Acne and unhealthy skin
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Excessive hair loss
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Overall sense of bloating
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Bodily swelling for no reason
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Hormone imbalances
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Weight Gain
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Power bowel function
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Excessive foul-smelling sweat
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Category 10
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Crave sweets during the day
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Irritable if meals are missed
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Depend on coffee to keep going/get started
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Get light-headed if meals are missed 
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Eating relieves fatigue
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Feel shaky , jittery, or have tremors
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Agitated, easily upset, nervous
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Poor memory, forgetful between meals
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Blurred vision
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Category 11
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Fatigue after meals
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Crave sweets during the day
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Eating sweets does not relieve cravings for sugar
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Must have sweets after meals
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Waist girth is equal or larger than hip girth
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Frequent urination
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Increased thirst and appetite
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Difficulty losing weight
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Category 12
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Cannot stay asleep
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Crave salt
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Slow starter in the morning
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Afternoon fatigue
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Dizziness when standing up quickly
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Afternoon headaches
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Headaches with exertion or stress
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Weak nails
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Category 13
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Cannot fall asleep
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Perspire easily 
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Under a high amount of stress
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Under a high amount of stress
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Weight gain when under stress
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Wake up tired even after 6 or more hours of sleep
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Excessive perspiration or  perspiration with little or no activity
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Excessive perspiration or  perspiration with little or no activity
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Category 14
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Edema and swelling in ankles and wrists
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Muscle cramping 
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Poor muscle endurance
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Frequent urination
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Crave salt
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Abnormal sweating from minimal activity
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Alternation in bowel regularity
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Inability to hold breath for long periods
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Shallow, rapid breathing
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Category 15
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Tire/sluggish
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Feel cold ----hands, feet, all over
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Require excessive amounts of sleep to function properly
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Increase in weight even with low-calorie diet
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Gain weight easily
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Difficult, infrequent bowel movements 
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Depression/lack of motivation
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Morning headaches that wear off as the day progresses
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Outer third of eyebrow thins
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Thinning of hair on scalp, face, or genitals, or excessive hair loss
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Dryness of skin and/or scalp
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0
1
2
3
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or
add "Other"
…
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Mental sluggishness
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1
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3
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…
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Category 16
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Heart palpitations
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1
2
3
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…
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Inward trembling
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1
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3
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…
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Increased pulse even at rest
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1
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3
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…
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Nervous and emotional
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1
2
3
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or
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…
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Insomnia
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1
2
3
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or
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…
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Night sweats
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1
2
3
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Difficulty gaining weight
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1
2
3
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Category 17 (Males Only)
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Urination difficulty or dribbling
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0
1
2
3
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or
add "Other"
…
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Frequent urination
Question Type
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0
1
2
3
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or
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…
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Pain inside of legs or heels
Question Type
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0
1
2
3
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…
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Feeling of incomplete bowel emptying
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0
1
2
3
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or
add "Other"
…
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Leg twitching at night
Question Type
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0
1
2
3
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…
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Category 18 (Males Only)
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Decreased libido
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0
1
2
3
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or
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…
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Decreased number of spontaneous morning erections
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1
2
3
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…
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Decreased fullness of erections
Question Type
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0
1
2
3
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or
add "Other"
…
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Difficulty maintaining morning erections
Question Type
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0
1
2
3
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or
add "Other"
…
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(0 points)
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Spells of mental fatigue
Question Type
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1
2
3
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or
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…
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(0 points)
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Inability to concentrate
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1
2
3
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…
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Episodes of depression
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2
3
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or
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…
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Muscle soreness
Question Type
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0
1
2
3
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or
add "Other"
…
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(0 points)
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Decreased physical stamina
Question Type
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0
1
2
3
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or
add "Other"
…
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(0 points)
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Unexplained weight gain
Question Type
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0
1
2
3
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or
add "Other"
…
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(0 points)
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Increase in fat distribution around chest and hips
Question Type
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0
1
2
3
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or
add "Other"
…
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(0 points)
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Sweating attacks
Question Type
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0
1
2
3
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or
add "Other"
…
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(0 points)
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More emotional than in the past
Question Type
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0
1
2
3
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or
add "Other"
…
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(0 points)
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Category 19 (Menstruating Females Only)
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Perimenopausal
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Yes
No
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or
add "Other"
…
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Alternating menstrual cycle lengths
Question Type
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No
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or
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…
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(0 points)
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Extended menstrual cycle (greater than 32 days)
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No
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or
add "Other"
…
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(0 points)
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Shortened menstrual cycle (less than 24 days)
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No
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or
add "Other"
…
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(0 points)
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Pain and cramping during periods
Question Type
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1
2
3
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…
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Scanty blood flow
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2
3
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…
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Heavy blood flow
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1
2
3
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…
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Heavy blood flow
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0
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2
3
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…
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Breast pain and swelling during menses
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0
1
2
3
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or
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…
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Pelvic pain during menses
Question Type
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0
1
2
3
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or
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…
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Irritable and depressed during menses
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1
2
3
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or
add "Other"
…
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Acne
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2
3
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or
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Facial hair growth
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3
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Hair loss/thinning
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2
3
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Category 20 (Menopausal Females Only)
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How many years have you been menopausal?
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Since menopause, do you ever have uterine bleeding?
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No
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Hot flashes
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2
3
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Mental fogginess
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2
3
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Disinterest in sex
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Mood swings
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2
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Depression
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3
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Painful intercourse
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2
3
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Shrinking breast
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2
3
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Facial hair growth
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Acne
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3
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Increased vaginal pain, dryness, or itching
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2
3
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Part III
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How many alcoholic beverages do you consume per week?
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Rate your stress level on a scale of 1-10 during the average week:
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How many caffeinated beverages do you consume per day?
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How many times do you eat fish per week?
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How many times do you eat out per week?
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How many times do you work out per week?
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How many times do you eat raw nuts or seeds per week?
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List the three worst foods you eat during the average week:
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List the three healthier foods you eat during the average week:
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Part IV
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Please list any medications you currently take and for what conditions:
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Please list any natural supplements you currently take and for what conditions:
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Age
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Date
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Sex
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  Please list your 5 major health concerns in order of importance
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Please check the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
Category I
  Feeling that bowels do not empty completely  
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Lower abdominal pain relieved by passing stool or gas
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Alternating constipation and diarrhea
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Diarrhea
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Constipation
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Hard, dry, or small stool
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Coated tongue or “fuzzy” debris on tongue
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Pass large amount of foul-smelling gas
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More than 3 bowel movements daily
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Use laxatives frequently
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Category 2
Increasing frequency of food reactions
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Unpredictable food reactions
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Aches, pains, and swelling throughout the body
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Unpredictable abdominal swelling
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Frequent bloating and distention after eating
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Category 3
Intolerance to smells
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Intolerance to jewelry
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Intolerance to shampoo, lotion, detergents, etc
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Intolerance to shampoo, lotion, detergents, etc
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Multiple smell and chemical sensitivities
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Constant skin outbreaks
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Category 4
Excessive belching, burping, or bloating
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Gas immediately following a meal
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Offensive breath
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Difficult bowel movements
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Sense of fullness during and after meals
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Difficulty digesting proteins and meats; undigested food found in stools
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Category 5
Stomach pain, burning, or aching 1-4 hours after eating
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Use of antacids
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Feel hungry an hour or two after eating
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Heartburn when lying down or bending forward
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No responses yet for this question.
Temporary relief by using antacids, food, milk, or carbonated beverages
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No responses yet for this question.
Digestive problems subside with rest and relaxation
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No responses yet for this question.
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
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No responses yet for this question.
Category 6
Difficulty digesting roughage and fiber
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Indigestion and fullness last 2-4 hours after eating
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Pain, tenderness, soreness on left side under rib cage
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Excessive passage of gas
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Nausea and/or vomiting
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Stool undigested, foul smelling, mucus like, greasy, or poorly formed
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Frequent loss of appetite
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Category 7
Abdominal distention after consumption of fiber, starches, and sugar
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Abdominal distention after certain probiotic or natural supplements
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Decreased gastrointestinal motility, constipation
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Increased gastrointestinal motility, diarrhea
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Alternating constipation and diarrhea
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Suspicion of nutritional malabsorption
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Frequent use of antacid medication
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Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?
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Category 8
Greasy or high-fat foods cause distress
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No responses yet for this question.
Lower bowel gas and/or bloating several hours after eating
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No responses yet for this question.
Bitter metallic taste in mouth, especially in the morning
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Burpy, fishy taste after consuming fish oils
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Unexplained itchy skin
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Yellowish cast to eyes
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Stool color alternates from clay colored to normal brown
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Reddened skin, especially palms
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Dry or flaky skin and/or hair
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History of gallbladder attacks or stones
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Have you had your gallbladder removed?
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Category 9
Acne and unhealthy skin
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No responses yet for this question.
Excessive hair loss
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No responses yet for this question.
Overall sense of bloating
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No responses yet for this question.
Bodily swelling for no reason
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Hormone imbalances
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Weight Gain
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Power bowel function
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Excessive foul-smelling sweat
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Category 10
Crave sweets during the day
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Irritable if meals are missed
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No responses yet for this question.
Depend on coffee to keep going/get started
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No responses yet for this question.
Get light-headed if meals are missed 
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No responses yet for this question.
Eating relieves fatigue
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Feel shaky , jittery, or have tremors
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No responses yet for this question.
Agitated, easily upset, nervous
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No responses yet for this question.
Poor memory, forgetful between meals
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No responses yet for this question.
Blurred vision
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Category 11
Fatigue after meals
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No responses yet for this question.
Crave sweets during the day
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No responses yet for this question.
Eating sweets does not relieve cravings for sugar
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No responses yet for this question.
Must have sweets after meals
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No responses yet for this question.
Waist girth is equal or larger than hip girth
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No responses yet for this question.
Frequent urination
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No responses yet for this question.
Increased thirst and appetite
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No responses yet for this question.
Difficulty losing weight
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No responses yet for this question.
Category 12
Cannot stay asleep
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No responses yet for this question.
Crave salt
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No responses yet for this question.
Slow starter in the morning
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No responses yet for this question.
Afternoon fatigue
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No responses yet for this question.
Dizziness when standing up quickly
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No responses yet for this question.
Afternoon headaches
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No responses yet for this question.
Headaches with exertion or stress
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No responses yet for this question.
Weak nails
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No responses yet for this question.
Category 13
Cannot fall asleep
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No responses yet for this question.
Perspire easily 
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No responses yet for this question.
Under a high amount of stress
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No responses yet for this question.
Under a high amount of stress
Copy
No responses yet for this question.
Weight gain when under stress
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No responses yet for this question.
Wake up tired even after 6 or more hours of sleep
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No responses yet for this question.
Excessive perspiration or  perspiration with little or no activity
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No responses yet for this question.
Excessive perspiration or  perspiration with little or no activity
Copy
No responses yet for this question.
Category 14
Edema and swelling in ankles and wrists
Copy
No responses yet for this question.
Muscle cramping 
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No responses yet for this question.
Poor muscle endurance
Copy
No responses yet for this question.
Frequent urination
Copy
No responses yet for this question.
Crave salt
Copy
No responses yet for this question.
Abnormal sweating from minimal activity
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No responses yet for this question.
Alternation in bowel regularity
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No responses yet for this question.
Inability to hold breath for long periods
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Shallow, rapid breathing
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No responses yet for this question.
Category 15
Tire/sluggish
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No responses yet for this question.
Feel cold ----hands, feet, all over
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No responses yet for this question.
Require excessive amounts of sleep to function properly
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No responses yet for this question.
Increase in weight even with low-calorie diet
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No responses yet for this question.
Gain weight easily
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No responses yet for this question.
Difficult, infrequent bowel movements 
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No responses yet for this question.
Depression/lack of motivation
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No responses yet for this question.
Morning headaches that wear off as the day progresses
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No responses yet for this question.
Outer third of eyebrow thins
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No responses yet for this question.
Thinning of hair on scalp, face, or genitals, or excessive hair loss
Copy
No responses yet for this question.
Dryness of skin and/or scalp
Copy
No responses yet for this question.
Mental sluggishness
Copy
No responses yet for this question.
Category 16
Heart palpitations
Copy
No responses yet for this question.
Inward trembling
Copy
No responses yet for this question.
Increased pulse even at rest
Copy
No responses yet for this question.
Nervous and emotional
Copy
No responses yet for this question.
Insomnia
Copy
No responses yet for this question.
Night sweats
Copy
No responses yet for this question.
Difficulty gaining weight
Copy
No responses yet for this question.
Category 17 (Males Only)
Urination difficulty or dribbling
Copy
No responses yet for this question.
Frequent urination
Copy
No responses yet for this question.
Pain inside of legs or heels
Copy
No responses yet for this question.
Feeling of incomplete bowel emptying
Copy
No responses yet for this question.
Leg twitching at night
Copy
No responses yet for this question.
Category 18 (Males Only)
Decreased libido
Copy
No responses yet for this question.
Decreased number of spontaneous morning erections
Copy
No responses yet for this question.
Decreased fullness of erections
Copy
No responses yet for this question.
Difficulty maintaining morning erections
Copy
No responses yet for this question.
Spells of mental fatigue
Copy
No responses yet for this question.
Inability to concentrate
Copy
No responses yet for this question.
Episodes of depression
Copy
No responses yet for this question.
Muscle soreness
Copy
No responses yet for this question.
Decreased physical stamina
Copy
No responses yet for this question.
Unexplained weight gain
Copy
No responses yet for this question.
Increase in fat distribution around chest and hips
Copy
No responses yet for this question.
Sweating attacks
Copy
No responses yet for this question.
More emotional than in the past
Copy
No responses yet for this question.
Category 19 (Menstruating Females Only)
Perimenopausal
Copy
No responses yet for this question.
Alternating menstrual cycle lengths
Copy
No responses yet for this question.
Extended menstrual cycle (greater than 32 days)
Copy
No responses yet for this question.
Shortened menstrual cycle (less than 24 days)
Copy
No responses yet for this question.
Pain and cramping during periods
Copy
No responses yet for this question.
Scanty blood flow
Copy
No responses yet for this question.
Heavy blood flow
Copy
No responses yet for this question.
Heavy blood flow
Copy
No responses yet for this question.
Breast pain and swelling during menses
Copy
No responses yet for this question.
Pelvic pain during menses
Copy
No responses yet for this question.
Irritable and depressed during menses
Copy
No responses yet for this question.
Acne
Copy
No responses yet for this question.
Facial hair growth
Copy
No responses yet for this question.
Hair loss/thinning
Copy
No responses yet for this question.
Category 20 (Menopausal Females Only)
How many years have you been menopausal?
Copy
No responses yet for this question.
Since menopause, do you ever have uterine bleeding?
Copy
No responses yet for this question.
Hot flashes
Copy
No responses yet for this question.
Mental fogginess
Copy
No responses yet for this question.
Disinterest in sex
Copy
No responses yet for this question.
Mood swings
Copy
No responses yet for this question.
Depression
Copy
No responses yet for this question.
Painful intercourse
Copy
No responses yet for this question.
Shrinking breast
Copy
No responses yet for this question.
Facial hair growth
Copy
No responses yet for this question.
Acne
Copy
No responses yet for this question.
Increased vaginal pain, dryness, or itching
Copy
No responses yet for this question.
Part III
How many alcoholic beverages do you consume per week?
Copy
No responses yet for this question.
Rate your stress level on a scale of 1-10 during the average week:
Copy
No responses yet for this question.
How many caffeinated beverages do you consume per day?
Copy
No responses yet for this question.
How many times do you eat fish per week?
Copy
No responses yet for this question.
How many times do you eat out per week?
Copy
No responses yet for this question.
How many times do you work out per week?
Copy
No responses yet for this question.
How many times do you eat raw nuts or seeds per week?
Copy
No responses yet for this question.
List the three worst foods you eat during the average week:
Copy
No responses yet for this question.
List the three healthier foods you eat during the average week:
Copy
No responses yet for this question.
Part IV
Please list any medications you currently take and for what conditions:
No responses yet for this question.
Please list any natural supplements you currently take and for what conditions:
No responses yet for this question.
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