Metabolic Assessment Form

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Symptom groups listed on this form are not intended to be

used as a diagnosis of any disease or condition

Name *

Age *

Email *

Phone Number *

Sex

Woman

Men

Transgender

non-binary

Other

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Date *

YYYY

Please list your 5 major health concerns in order of importance.
*

Part I

Please select 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 II

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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 III

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Intolerance to smells

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Intolerance to jewelry

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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 IV

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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 V

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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

Clear selection

Category VI

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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 VII

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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? Frequent use of antacid medication

Yes

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Category VIII

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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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Category IX

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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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Poor bowel function

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Excessively foul-smelling sweat

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Category X

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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
Blurred vision

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Category XI

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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 XII

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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
Weak nails

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Weak nails

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Category XIII

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Cannot fall asleep

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Perspire easily

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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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Category XIV

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

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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Frequent thirst

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Crave salt

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Abnormal sweating from minimal activity

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Alteration 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 XV

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Tired/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

Clear selection

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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Mental sluggishness

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Category XVI

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Heart palpitations

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Inward trembling

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Increased pulse even at rest

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Nervous and emotional

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Insomnia

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Night sweats

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Difficulty gaining weight

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Category XVII (Males Only)

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Urination difficulty or dribbling

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Frequent urination

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Pain inside of legs or heels

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Feeling of incomplete bowel emptying

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Leg twitching at night

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Category XVIII (Males Only)

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Decreased libido

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Decreased number of spontaneous morning erections

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Decreased fullness of erections

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Difficulty maintaining morning erections

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Spells of mental fatigue

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Inability to concentrate

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Episodes of depression

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Muscle soreness

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Decreased physical stamina

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Unexplained weight gain

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Increase in fat distribution around chest and hips

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Sweating attacks

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More emotional than in the past

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Category XIX (Menstruating Females Only)

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Perimenopausal

Yes

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Alternating menstrual cycle lengths

Yes

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Extended menstrual cycle (greater than 32 days)

Yes

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Shortened menstrual cycle (less than 24 days)

Yes

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Pain and cramping during periods

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Scanty blood flow

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Heavy blood flow

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Breast pain and swelling during menses

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Pelvic pain during menses

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Irritable and depressed during menses

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Acne

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Facial hair growth

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Hair loss/thinning

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Category XX (Menopausal Females Only)

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

How many years have you been menopausal?

Hot flashes

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Mental fogginess

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Disinterest in sex

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Mood swings

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Depression

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Painful intercourse

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Shrinking breasts

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Facial hair growth

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Acne

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Increased vaginal pain, dryness, or itching

Clear selection

PART II

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat 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:

Rate your stress level on a scale of 1-10 during the average week

How many times do you eat fish per week?

How many times do you work out per week?

PART III

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

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