Metabolic Assessment Form Page 2
Download a blank fillable Metabolic Assessment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Metabolic Assessment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Category IX
Category XIV
Cannot fall asleep
0
1
2
3
Urination difficulty or dribbling
0
1
2
3
Perspire easily
0
1
2
3
Urination frequent
0
1
2
3
Under high amounts of stress
Pain inside of legs or heels
0
1
2
3
0
1
2
3
Weight gain when under stress
0
1
2
3
Feeling of incomplete bowel evacuation
0
1
2
3
Wake up tired even after 6 or more hours of sleep
0
1
2
3
Leg nervousness at night
0
1
2
3
Excessive perspiration or perspiration with
little or no activity
0
1
2
3
Category XV
Decrease in libido
0
1
2
3
Decrease in spontaneous morning erections
0
1
2
3
Category X
Decrease in fullness of erections
0
1
2
3
Tired, sluggish
0
1
2
3
Difficulty in maintain morning erections
0
1
2
3
Feel cold – hands, feet, all over
0
1
2
3
Spells of mental fatigue
0
1
2
3
Require excessive amounts of sleep to
Inability to concentrate
0
1
2
3
function properly
0
1
2
3
Episodes of depression
0
1
2
3
Increase in weight gain even with low-calorie diet
0
1
2
3
Muscle soreness
0
1
2
3
Gain weight easily
0
1
2
3
Decrease in physical stamina
0
1
2
3
Difficult, infrequent bowel movements
0
1
2
3
Unexplained weight gain
0
1
2
3
Depression, lack of motivation
0
1
2
3
Increase in fat distribution around chest and hips
0
1
2
3
Morning headaches that wear off
Sweating attacks
0
1
2
3
as the day progresses
0
1
2
3
More emotional than in the past
0
1
2
3
Outer third of eyebrow thins
0
1
2
3
Thinning of hair on scalp, face or genitals or
excessive falling hair
0
1
2
3
Category XVI
Dryness of skin and/or scalp
0
1
2
3
Are you perimenopausal
Yes
No
Mental sluggishness
Alternating menstrual cycle lengths
0
1
2
3
Yes
No
Extended menstrual cycle, greater than 32 days
Yes
No
]
Shortened menses, less than every 24 days
Yes
No
Category XI
Pain and cramping during periods
0
1
2
3
Heart palpations
0
1
2
3
Scanty blood flow
0
1
2
3
Inward trembling
0
1
2
3
Heavy blood flow
0
1
2
3
Increased pulse even at rest
0
1
2
3
Breast pain and swelling during menses
0
1
2
3
Nervous and emotional
0
1
2
3
Pelvic pain during menses
0
1
2
3
Insomnia
0
1
2
3
Irritable and depressed during menses
0
1
2
3
Night sweats
0
1
2
3
Acne break outs
0
1
2
3
Difficulty gaining weight
0
1
2
3
Facial hair growth
0
1
2
3
Hair loss/thinning
0
1
2
3
Category XII
Diminished sex drive
0
1
2
3
Category XVII
Menstrual disorders or lack of menstruation
0
1
2
3
How many years have you been menopausal?
________
Increased ability to eat sugars without symptoms
0
1
2
3
Since menopause, do you ever have uterine bleeding?
Yes
No
Hot flashes
0
1
2
3
Category XIII
Mental fogginess
0
1
2
3
Increased sex drive
Disinterest in sex
0
1
2
3
0
1
2
3
Tolerance to sugars reduced
Mood swings
0
1
2
3
0
1
2
3
“Splitting” type headaches
0
1
2
3
Depression
0
1
2
3
Painful intercourse
0
1
2
3
Shrinking breasts
0
1
2
3
Facial hair growth
0
1
2
3
Acne
0
1
2
3
Increased vaginal pain, dryness or itching
0
1
2
3
Thank you for taking the time to fill out this form!
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical