Metabolic Assessment Form - Replenishpdx
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Instructions:
Please complete the Metabolic Assessment, save
Metabolic Assessment Form
your results and submit using the buttons above.
☐M ☐F
Name:
Age:
Gender:
Phone number:
E-mail address:
PART I
Please list your 3 main health concerns in order of importance:
List any medicine you are currently taking:
List all vitamins, minerals, herbs and nutritional supplements you are now taking:
What dietary parameters do you live by?
Please list any diagnosed conditions:
PART II
Please select the appropriate number on all questions below.
0 as the least/never to 3 as the most/always.
Category I
0
1
2
3
Category VI (continued)
0
1
2
3
Feeling that bowels do not empty completely
Excessive passage of gas
Lower abdominal pain relieved by passing stool or gas
Nausea and/or vomiting
Alternating constipation and diarrhea
Stool undigested, foul smelling, mucous like,
Diarrhea
greasy, or poorly formed
Constipation
Frequent urination
Hard, dry, or small stool
Increased thirst and appetite
Coated tongue or “fuzzy” debris on tongue
Difficulty losing weight
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Category VII
0
1
2
3
Use laxatives frequently
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours
after eating
Category II
0
1
2
3
Increasing frequency of food reactions
Bitter metallic taste in mouth, especially in the morning
Unpredictable food reactions
Unexplained itchy skin
Aches, pains, and swelling throughout the body
Yellowish cast to eyes
Unpredictable bloating and distention after eating
Stool color alternates from clay colored to
Frequent bloating and distention after eating
normal brown
Abdominal intolerance to sugars and starches
Reddened skin, especially palms
Dry or flaky skin and/or hair
Category III
0
1
2
3
History of gallbladder attacks or stones
☐Yes ☐No
No
Intolerance to smells
Have you had your gallbladder removed?
Yes
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc.
Category VIII
0
1
2
3
Multiple smell and chemical sensitivities
Acne and unhealthy skin
Constant skin outbreaks
Excessive hair loss
Overall sense of bloating
0
1
2
3
Bodily swelling for no reason
Category IV
Excessive belching, burping, or bloating
Hormone imbalances
Gas immediately following a meal
Weight gain
Offensive breath
Poor bowel function
Difficult bowel movement
Excessively foul-smelling sweat
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables;
Category IX
0
1
2
3
undigested food found in stools
Crave sweets during the day
Irritable if meals are missed
Category V
0
1
2
3
Depend on coffee to keep going/get started
Stomach pain, burning, or aching 1-4 hours after eating
Get light-headed if meals are missed
Use antacids
Eating relieves fatigue
Feel hungry an hour or two after eating
Feel shaky, jittery, or have tremors
Heartburn when lying down or bending forward
Agitated, easily upset, nervous
Temporary relief by using antacids, food, milk, or
Poor memory/forgetful
carbonated beverages
Blurred vision
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus,
Category X
0
1
2
3
peppers, alcohol, and caffeine
Fatigue after meals
0
1
2
3
Crave sweets during the day
Category VI
Eating sweets does not relieve cravings for sugar
Roughage and fiber cause constipation
Must have sweets after meals
Indigestion and fullness last 2-4 hours after eating
Waist girth is equal or larger than hip girth
Pain, tenderness, soreness on left side under rib cage
Frequent urination
Increased thirst and appetite
Difficulty losing weight
Replenish PDX
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
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