Metabolic Assessment Form
ADVERTISEMENT
1
2METABOLIC ASSESSMENT FORM
Name: ____________________________________________________ Age: ______ Sex: _____ Date: ______________
PART I
Please list your 3 major health concerns in your order of importance:
List any/all pills you take & the reason why:
1)
2)
3)
PART II
Please circle the appropriate number “0 - 3” on all questions below.
0 = never, 1 = occasionally, 2 = somewhat frequently, 3 = very frequently
Category I: Colon
Category V: Biliary Insufficiency/Statis
Feeling that bowels do not empty completely
0
1
2
3
Greasy or high fat foods cause distress
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
0
1
2
3
Bitter metallic taste in mouth,
0
1
2
3
Constipation
0
1
2
3
especially in the morning
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
0
1
2
3
Stool color alternates from clay colored
More than 3 bowel movements daily
0
1
2
3
to normal brown
0
1
2
3
Do you use laxatives frequently
0
1
2
3
Reddened skin, especially palms
0
1
2
3
Category II: Hypochlorydia
Dry or flaky skin and/or hair
0
1
2
3
Excessive belching burping or bloating
0
1
2
3
History of gallbladder attacks or stones
0
1
2
3
Gas immediately following a meal
0
1
2
3
Have you had your gallbladder removed
Yes
No
Offensive breath
0
1
2
3
Category VI: Hypoglycemia
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 and if meals are missed
0
1
2
3
Category III: Hyperacidity (Ulcer)
Eating relieves fatigue
0
1
2
3
Stomach pain, burning or aching 1- 4 hours after eating 0
1
2
3
Feel shaky, jittery, tremors
0
1
2
3
Do you frequently use antacids
0
1
2
3
Agitated, easily upset, nervous
0
1
2
3
Feeling hungry an hour or two after eating
0
1
2
3
Poor memory, forgetful
0
1
2
3
Heartburn when lying down or bending forward
0
1
2
3
Blurred vision
0
1
2
3
Temporary relief from antacids, food,
Category VII: Insulin Resistance
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
Category IV: Small Intestine (Pancreas)
Waist girth is equal or larger than hip girth
Yes
No
Roughage and fiber cause constipation
0
1
2
3
Frequent urination
0
1
2
3
Indigestion and fullness lasts 2-4
Increased thirst & appetite
0
1
2
3
hours after eating
0
1
2
3
Difficulty losing weight
0
1
2
3
Pain, tenderness, soreness on left side
Category VIII: Adrenal Hypofunction
under rib cage bloated
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
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical