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