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Metabolic Assessment Form

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MM slash DD slash YYYY

PART I

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

PART II

Please circle 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*
Lower abdominal pain relieved by passing stool or gas*
Alternating constipation and diarrhea*
Diarrhea*
Constipation*
Hard, dry, or small stool*
Coated tongue or “fuzzy” debris on tongue*
Pass large amount of foul-smelling gas*
More than 3 bowel movements daily*
Use laxatives frequently*

CATEGORY II

Increasing frequency of food reactions*
Unpredictable food reactions*
Aches, pains, and swelling throughout the body*
Unpredictable abdominal swelling*
Frequent bloating and distention after eating*
Abdominal intolerance to sugars and starches*

CATEGORY III

Intolerance to smells*
Intolerance to jewelry*
Intolerance to shampoo, lotion, detergents, etc.*
Multiple smell and chemical sensitivities*
Constant skin outbreaks*

CATEGORY IV

Excessive belching, burping, or bloating*
Gas immediately following a meal*
Offensive breath*
Difficult bowel movement*
Sense of fullness during and after meals*
Difficulty digesting fruits and vegetables; undigested food found in stools*

CATEGORY V

Stomach pain, burning, or aching 1-4 hours after eating*
Use antacids*
Feel hungry an hour or two after eating*
Heartburn when lying down or bending forward*
Temporary relief by using antacids, food, milk, or carbonated beverages*
Digestive problems subside with rest and relaxation*
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine*

CATEGORY VI

Roughage and fiber cause constipation*
Indigestion and fullness last 2-4 hours after eating*
Pain, tenderness, soreness on left side under rib cage*
Excessive passage of gas*
Nausea and/or vomiting*
Stool undigested, foul smelling, mucous like, greasy, or poorly formed*
Frequent urination*
Increased thirst and appetite*

CATEGORY VII

Greasy or high-fat foods cause distress*
Lower bowel gas and/or bloating several hours after eating*
Bitter metallic taste in mouth, especially in the morning*
Burpy, fishy taste after consuming fish oils*
Difficulty losing weight*
Unexplained itchy skin*
Yellowish cast to eyes*
Stool color alternates from clay colored to normal brown*
Reddened skin, especially palms*
Dry or flaky skin and/or hair*
History of gallbladder attacks or stones*
Have you had your gallbladder removed?*

CATEGORY VIII

Acne and unhealthy skin*
Excessive hair loss*
Overall sense of bloating*
Bodily swelling for no reason*
Hormone imbalances*
Weight gain*
Poor bowel function*
Excessively foul-smelling sweat*

CATEGORY IX

Crave sweets during the day*
Irritable if meals are missed*
Depend on coffee to keep going/get started*
Get light-headed if meals are missed*
Eating relieves fatigue*
Feel shaky, jittery, or have tremors*
Agitated, easily upset, nervous*
Poor memory/forgetful*
Blurred vision*

CATEGORY X

Fatigue after meals*
Crave sweets during the day*
Eating sweets does not relieve cravings for sugar*
Must have sweets after meals*
Waist girth is equal or larger than hip girth*
Frequent urination*
Increased thirst and appetite*
Difficulty losing weight*

CATEGORY XI

Cannot stay asleep*
Crave salt*
Slow starter in the morning*
Afternoon fatigue*
Dizziness when standing up quickly*
Afternoon headaches*
Headaches with exertion or stress*
Weak nails*

CATEGORY XII

Cannot fall asleep*
Perspire easily*
Under high amount of stress*
Weight gain when under stress*
Wake up tired even after 6 or more hours of sleep*
Excessive perspiration or perspiration with little or no activity*

CATEGORY XIII

Edema and swelling in ankles and wrists*
Muscle cramping*
Poor muscle endurance*
Frequent urination*
Frequent thirst*
Crave salt*
Abnormal sweating from minimal activity*
Alteration in bowel regularity*
Inability to hold breath for long periods*
Shallow, rapid breathing*

CATEGORY XIV

Tired/sluggish*
Feel cold―hands, feet, all over*
Require excessive amounts of sleep to function properly*
Increase in weight even with low-calorie diet*
Gain weight easily*
Difficult, infrequent bowel movements*
Depression/lack of motivation*
Morning headaches that wear off as the day progresses*
Outer third of eyebrow thins*
Thinning of hair on scalp, face, or genitals, or excessive hair loss*
Dryness of skin and/or scalp*
Mental sluggishness*

CATEGORY XV

Heart palpitations*
Inward trembling*
Increased pulse even at rest*
Nervous and emotional*
Insomnia*
Night sweats*
Difficulty gaining weight*

CATEGORY XVI

Diminished sex drive*
Menstrual disorders or lack of menstruation*
Increased ability to eat sugars without symptoms*

CATEGORY XVII

Increased sex drive*
Tolerance to sugars reduced*
“Splitting” - type headaches*

CATEGORY XVIII (MALES ONLY)

Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night

CATEGORY XIX (MALES ONLY)

Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past

CATEGORY XX (MENSTRUATING FEMALES ONLY)

Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning

CATEGORY XXI (MENOPAUSAL FEMALES ONLY)

Since menopause, do you ever have uterine bleeding?
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness, or itching

PART III

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*
Please list any natural supplements you currently take and for what conditions*
This field is for validation purposes and should be left unchanged.
Contact Info
1850 Riverside Ave Suite #170
Rialto, CA 92376

Phone: 909-874-6640

Office Hours
Mon - Fri: 9am - 12pm & 2pm - 5pm
Sat & Sun: Closed

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