Metabolic Assessment Form
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1
2Metabolic Assessment Form
Name:
Age:
Sex:
Date:
____________________________________________________
______
_____
______________
PART I
Please list the 5 major health concerns in your order of importance:
1. _____________________________________________________________________________________________
2. _____________________________________________________________________________________________
3. _____________________________________________________________________________________________
4. _____________________________________________________________________________________________
5. _____________________________________________________________________________________________
PART II
Please circle the appropriate number “0 - 3” on all questions below.
0 as the least/never to 3 as the most/always.
Category I
Category V
Feeling that bowels do not empty completely
Greasy or high fat foods cause distress
0
1
2
3
0
1
2
3
Lower abdominal pain relief by passing stool or gas
0
1
2
3
Lower bowel gas and or bloating
Alternating constipation and diarrhea
0
1
2
3
several hours after eating
0
1
2
3
Diarrhea
Bitter metallic taste in mouth,
0
1
2
3
Constipation
especially in the morning
0
1
2
3
0
1
2
3
Hard, dry, or small stool
0
1
2
3
Unexplained itchy skin
0
1
2
3
Coated tongue of “fuzzy” debris on tongue
0
1
2
3
Yellowish cast to eyes
0
1
2
3
Pass large amount of foul smelling gas
Stool color alternates from clay colored
0
1
2
3
More than 3 bowel movements daily
to normal brown
0
1
2
3
0
1
2
3
use laxatives frequently
0
1
2
3
Reddened skin, especially palms
0
1
2
3
Dry or flaky skin and/or hair
0
1
2
3
History of gallbladder attacks or stones
Category II
0
1
2
3
Excessive belching, burping, or bloating
Have you had your gallbladder removed
0
1
2
3
Yes
No
Gas immediately following a meal
0
1
2
3
Offensive breath
0
1
2
3
Category VI
Difficult bowel movements
0
1
2
3
Crave sweets during the day
0
1
2
3
Sense of fullness during and after meals
0
1
2
3
Irritable if meals are missed
0
1
2
3
Difficulty digesting fruits and vegetables;
Depend on coffee to keep yourself going or started
0
1
2
3
undigested foods found in stools
0
1
2
3
Get lightheaded if meals are missed
0
1
2
3
Eating relieves fatigue
0
1
2
3
Category III
Feel shaky, jittery, tremors
0
1
2
3
Stomach pain, burning, or aching 1- 4 hours after eating
0
1
2
3
Agitated, easily upset, nervous
0
1
2
3
Do you frequently use antacids?
0
1
2
3
Poor memory, forgetful
0
1
2
3
Feeling hungry an hour or two after eating
0
1
2
3
Blurred vision
0
1
2
3
Heartburn when lying down or bending forward
0
1
2
3
Temporary relief from antacids, food,
Category VII
milk, carbonated beverages
0
1
2
3
Fatigue after meals
0
1
2
3
Digestive problems subside with rest and relaxation
0
1
2
3
Crave sweets during the day
0
1
2
3
Heartburn due to spicy foods, chocolate, citrus,
Eating sweets does not relieve cravings for sugar
0
1
2
3
peppers, alcohol, and caffeine
0
1
2
3
Must have sweets after meals
0
1
2
3
Waist girth is equal or larger than hip girth
0
1
2
3
Category IV
Frequent urination
0
1
2
3
Roughage and fiber cause constipation
0
1
2
3
Increased thirst & appetite
0
1
2
3
Indigestion and fullness lasts 2-4
Difficulty losing weight
0
1
2
3
hours after eating
0
1
2
3
Pain, tenderness, soreness on left side
Category VIII
under rib cage
0
1
2
3
Cannot stay asleep
0
1
2
3
Excessive passage of gas
0
1
2
3
Crave salt
0
1
2
3
Nausea and/or vomiting
0
1
2
3
Slow starter in the morning
0
1
2
3
Stool undigested, foul smelling,
Afternoon fatigue
0
1
2
3
mucous-like, greasy, or poorly formed
0
1
2
3
Dizziness when standing up quickly
0
1
2
3
Frequent urination
0
1
2
3
Afternoon headaches
0
1
2
3
Increased thirst and appetite
0
1
2
3
Headaches with exertion or stress
0
1
2
3
Difficulty losing weight
0
1
2
3
Weak nails
0
1
2
3
Symptom groups listed in this f
are not intended to be used as a diagnosis of any disease condition.
For nutritional purposes only.
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