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  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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0
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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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YES
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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YES
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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