Metabolic Assessment Form - Replenishpdx Page 2
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1
2Category XI
0
1
2
3
Category XVII
0
1
2
3
Cannot stay asleep
Increased sex drive
Crave salt
Tolerance to sugars reduced
"Splitting" – type headaches
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Category XVIII (Males Only)
0
1
2
3
Afternoon headaches
Urination difficulty or dribbling
Headaches with exertion or stress
Frequent urination
Weak nails
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night
Category XII
0
1
2
3
Cannot fall asleep
Perspire easily
Category XIX (Males Only)
0
1
2
3
Under high amount of stress
Decreased libido
Weight gain when under stress
Decreased number of spontaneous morning erections
Wake up tired even after 6 or more hours of sleep
Decreased fullness of erections
Excessive perspiration or perspiration with little
Difficulty maintaining morning erections
or no activity
Spells of mental fatigue
Inability to concentrate
Category XIII
0
1
2
3
Episodes of depression
Edema and swelling in ankles and wrists
Muscle soreness
Muscle cramping
Decreased physical stamina
Poor muscle endurance
Unexplained weight gain
Frequent urination
Increase in fat distribution around chest and hips
Frequent thirst
Sweating attacks
Crave salt
More emotional than in the past
Abnormal sweating from minimal activity
Alteration in bowel regularity
Category XX (Menstruating Females Only)
0
1
2
3
Inability to hold breath for long periods
Perimenopausal
Shallow, rapid breathing
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Category XIV
0
1
2
3
Shortened menstrual cycle (less than 24 days)
Tired/sluggish
Pain and cramping during periods
Feel cold—hand, feet, all over
Scanty blood flow
Require excessive amount of sleep to function properly
Heavy blood flow
Increase in weight even with low-calorie diet
Breast pain and swelling during menses
Gain weight easily
Pelvic pain during menses
Difficult, infrequent bowel movements
Irritable and depressed during menses
Depression/lack of motivation
Acne
Morning headaches that wear off as the day progresses
Facial hair growth
Outer third of eyebrow thins
Hair loss/thinning
Thinning of hair on scalp, face, or genitals, or excessive
hair loss
Category XXI (Menopausal Females Only)
0
1
2
3
Dryness of skin and/or scalp
How many years have you been menopausal?
years
☐Yes ☐No
Mental sluggishness
Since menopause, do you ever have uterine bleeding?
Hot flashes
Category XV
0
1
2
3
Mental fogginess
Heart palpitations
Disinterest in sex
Inward trembling
Mood swings
Increased pulse even at rest
Depression
Nervous and emotional
Painful intercourse
Insomnia
Shrinking breasts
Night sweats
Facial hair growth
Difficulty gaining weight
Acne
Increased vaginal pain, dryness, or itching
Category XVI
0
1
2
3
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
PART III
How many alcoholic beverages do you consume per week?
Rate your stress level on a scale of 1-10 during the average week:
How many caffeinated beverages do you consume per day?
How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work 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:
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:
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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