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Section 1 of 1
Form title
Metabolic Assessment Form
Form description
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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Sex
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Please list your 5 major health concerns in order of importance
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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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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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Category I
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Feeling that bowels do not empty completely
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Feeling that bowels do not empty completely
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Lower abdominal pain relieved by passing stool or gas
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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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Alternating constipation and diarrhea
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Diarrhea
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Diarrhea
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Option 5
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Constipation
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Constipation
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Hard, dry, or small stool
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Hard, dry, or small stool
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Coated tongue or “fuzzy” debris on tongue
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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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Pass large amount of foul-smelling gas
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More than 3 bowel movements daily
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More than 3 bowel movements daily
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Use laxatives frequently
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Use laxatives frequently
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Category 2
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Category 2
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Increasing frequency of food reactions
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Increasing frequency of food reactions
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Unpredictable food reactions
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Unpredictable food reactions
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Aches, pains, and swelling throughout the body
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Aches, pains, and swelling throughout the body
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Unpredictable abdominal swelling
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Unpredictable abdominal swelling
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