metabolic assessment form

1. name: *
2. date: *
Please choose the appropriate number 1-5 on all statements below.  
                  1=This is not my problem (no issues)
                  3=This is an ongoing pesky problem (moderate issue)
                  5=This is a BIG problem (severe issue) 
part 1-ST
Do you have. . .
3. excessive burping *
1 2 3 4 5
4. gas and/or bloating immediately following a meal *
1 2 3 4 5
5. consistently bad breath *
1 2 3 4 5
6. difficult bowel movements *
1 2 3 4 5
7. sense of fullness during and/or after meals *
1 2 3 4 5
8. difficulty digesting fruits and vegetables; undigested food found in stools *
1 2 3 4 5
9. heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and/or caffeine *
1 2 3 4 5
part 2-PA
Do you have. . . 
10. excessive passage of gas *
1 2 3 4 5
11. nausea *
1 2 3 4 5
12. stools with undigested food and/or stools that are very bad smelling, mucus-y or greasy, or poorly formed *
1 2 3 4 5
13. constipation when you consume roughage and fiber *
1 2 3 4 5
part 3-GB
Do you have. . .
14. lower bowel gas or bloating several hours after eating *
1 2 3 4 5
15. distress when consuming greasy or high fat foods *
1 2 3 4 5
16. bitter metallic taste in mouth, especially in the morning *
1 2 3 4 5
17. unexplained itchy skin *
1 2 3 4 5
18. yellowish cast to eyes *
1 2 3 4 5
19. stool color alternates from clay-colored to dark brown *
1 2 3 4 5
20. history of gallbladder attacks or stones *
1 2 3 4 5
21. have you had your gallbladder removed? *
part 4-IntPer
Do you have. . . 
22. increasing frequency of food reactions *
1 2 3 4 5
23. unpredictable food reactions *
1 2 3 4 5
24. unpredictable abdominal swelling including gas and/or bloating *
1 2 3 4 5
25. frequent bloating and distension after eating *
1 2 3 4 5
26. problems with foods with sugars and/or starches *
1 2 3 4 5
part 5-L
Do you have. . .
27. increased sensitivity to smells *
1 2 3 4 5
28. intolerance to lotions, shampoos, detergents, etc. *
1 2 3 4 5
29. multiple chemical sensitivities *
1 2 3 4 5
30. acne or other skin breakouts *
1 2 3 4 5
31. weight gain *
1 2 3 4 5
32. excessive foul-smelling sweat or NO sweat *
1 2 3 4 5
part 6-BS
Do you have. . . 
33. cravings for sweets during the day *
1 2 3 4 5
34. irritability if meals are missed *
1 2 3 4 5
35. lightheaded feelings if meals are missed *
1 2 3 4 5
36. a dependency on coffee in the morning to "get" going *
1 2 3 4 5
37. fatigue that is relieved with eating *
1 2 3 4 5
38. fatigue following meals *
1 2 3 4 5
39. shakiness, or jittery feelings if meals are missed *
1 2 3 4 5
40. increasing nervousness, agitation or upset feelings *
1 2 3 4 5
41. a problem with forgetfulness *
1 2 3 4 5
42. blurred vision *
1 2 3 4 5
43. a big sweet tooth *
1 2 3 4 5
44. sweets regularly after meals or a 'need' for sweets after meals *
1 2 3 4 5
part 7-AD
Do you have. . . 
45. problems with falling asleep *
1 2 3 4 5
46. problems with staying asleep *
1 2 3 4 5
47. tiredness when waking up after 6 or more hours of sleep *
1 2 3 4 5
48. fatigue in the afternoons *
1 2 3 4 5
49. cravings for salt *
1 2 3 4 5
50. cravings for fat *
1 2 3 4 5
51. cravings for sugar or other carbs *
1 2 3 4 5
52. excessive sweating with activity or with NO activity *
1 2 3 4 5
53. dizziness when standing up too quickly *
1 2 3 4 5
part 8-HRTH
Do you have . . .
54. increased sex drive *
1 2 3 4 5
55. "splitting" type headaches *
1 2 3 4 5
part 9-HOTH
Do you have . . .
56. feelings of tiredness/sluggishness *
1 2 3 4 5
57. cold hands/feet/other body part(s) *
1 2 3 4 5
58. a need for excessive amounts of sleep to function properly *
1 2 3 4 5
59. a recent increase in weight *
1 2 3 4 5
60. a tendency to gain weight more easily than ever before *
1 2 3 4 5
61. thinning of the outer third of your eyebrow and/or on your scalp *
1 2 3 4 5
62. dry skin and/or scalp *
1 2 3 4 5
63. mental sluggishness *
1 2 3 4 5
64. headaches in the morning that wear off as the day progresses *
1 2 3 4 5
65. menstrual disorders or lack of menstruation
1 2 3 4 5
part 10-C
Do you have . . .
66. feelings that bowels do not empty completely *
1 2 3 4 5
67. lower abdominal pain that is relieved by passing stools or gas *
1 2 3 4 5
68. alternating constipation and diarrhea *
1 2 3 4 5
69. diarrhea *
1 2 3 4 5
70. constipation *
1 2 3 4 5
71. hard, dry, or small stools *
1 2 3 4 5
72. large amounts of foul-smelling gas *
1 2 3 4 5
73. more than 3 bowel movements daily *
1 2 3 4 5
74. laxatives you frequently use *
1 2 3 4 5