• METABOLIC ASSESSMENT FORM

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  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Feeling bowels do not empty completely
    Lower abdominal pain relieved by passing gas or stool
    Alternating constipation and diarrhea
    Diarrhea
    Constipation
    Hard, dry, or small stool
    Coated tongue or "fuzzy" debris on tongue
    Pass large amount of foul smelling gas
    More than 3 bowel movement daily
    Use laxatives frequently
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Increasing frequency of food reactions
    Unpredictable food reactions
    Aches,pains,swelling throughout the body
    Unpredictable abdominal swelling
    Frequent bloating and distension after eating
    Abdominal intolerance to sugars and starches
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Intolerance to smells
    Intolerance to jewelry
    Intolerance to shampoo,lotions,detergents,etc
    Multiple smell and chemical sensitivities
    Constant skin outbreaks
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Excessive belching,burping or bloating
    Gas immediately following a meal
    Offensive Breath
    Difficult bowel movement
    Sense of fullness during and after meals
    Difficulty digesting fruits and vegetables:undigested food found in stools
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Stomach pain, burning, or aching 1-4 hours after eating
    Use antacids
    Feel hungry an hour or two after eating
    Heartburn when laying down or bending forward
    Temporary relief by using antacids, food,milk or carbonated beverages
    Digestive problems subside with rest and relaxation
    Heartburn due to spicy foods, chocolate,citrus,peppers,alcohol and caffeine
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Roughage and fiber cause constipation
    Indigestion and fullness last 2-4 hours after eating
    Pain.tenderness soreness on left side under ribcage
    Excessive passage of gas
    Nausea and/or vomiting
    Stool undigested, fouls smelling, mucus like, greasy or poorly formed
    Frequent urination
    Increased thirst and appetite
    Difficulty loosing weight
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Greasy or high-fat foods cause distress
    lower bowel gas and/or bloating several hours after eating
    Bitter metalicl taste in mouth, especially in the morning
    Unexplained itchy skin
    Yellowish cast to eyes
    Stool color alternates from clay colored to normal brown
    Reddened skin, especially palms
    Dry or flaky skin or hair
    History of gallbladder attacks or stones
    Have you had your gallbladder removed
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Acne and unhealthy skin
    Excessive hair loss
    Overall sense of bloating
    Bodily swelling for no reason
    Hormone imbalances
    Weight gain
    Poor bowel movement
    Excessive foul-smelling sweat
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Crave sweets during the day
    Irritable if meals are missed
    Depend on coffee to keep going/get started
    Get light headed if meals are missed
    Eating relieves fatigue
    Feel shaky, jittery, or have tremores
    Agitated,easily upset, nervous
    Poor memory/forgetful
    Blurred vision
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Fatigue after meals
    Crave sweets during the day
    Eating sweets does not relieve cravings for sugar
    Must have sweets after meals
    Waist girth is equal or larger than hip girth
    Frequent urination
    Increased thirst or appettite
    Difficulty loosing weight
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Cannot stay asleep
    Crave salt
    Slow starter in the morning
    Afternoon fatigue
    Dizziness when standing up quickly
    Afternoon headaches
    Headaches with exertion or stress
    Weak nails
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Cannot fall asleep
    Perspire easily
    Under high amount of stress
    Weight gain under stress
    Wake up titrd even after 6 hours or more of sleep
    Excessive perspiration or perspiration with little or no activity
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Edema and swelling in ankles and wrists
    Muscle cramping
    Poor muscle endurance
    Frequent urination
    Crave salt
    Abnormal sweating from minimal activity
    Alteration in bowel regularity
    Inability to hold breath for long periods
    Shallow, rapid breathing
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Tired/Slugish
    Feel cold- hands, feet, all over
    Require excessive amounts of sleep to function properly
    Increase in weight gain even with low -calorie diet
    Gain weight easily
    Difficult, infrequent bowel movements
    Depression/lack of motivation
    Morning headaches that wear off as the day progresses
    Outer third of eyebrow thins
    Thinning of hair on scalp, face, or genitals, or excessive hair loss
    Dryness odfskin and/or scalp
    Mental sluggishness
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Heart palpitations
    Inward trembling
    Increased pulse even at rest
    Nervous and emotional
    Insomnia
    Night sweats
    Difficulty gaining weight
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Diminish sex drive
    Menstrual disorders or lack of menstruation
    Increased ability to eat sugars without symptoms
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Increased sex drive
    Tolerance to sugars reduced
    "Splitting " type headaches
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Urination difficulty or dribbling
    Frequent urination
    Pain inside of legs or heels
    Feeling of incomplete bowel emptying
    Leg twitching at night
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Decreased libido
    Decreased number of spontaneous morning erections
    Decreased fullness of erections
    Difficulty maintaining morning erections
    Spells of mental fatigue
    Inability to concentrate
    Episodes of depression
    Muscle soreness
    Decreased physical stamina
    Unexplained weight gain
    Increased in fat distribution around chest and hips
    Sweating attacks
    More emotional than in the past
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Perimenopausal
    Alternating menstrual cycle lenghts
    Extended menstrual cycles (greater than 32 days)
    Shortened menstrual cycle (less than 24 days)
    Pain and cramping during periods
    Scanty blood flow
    Heavy blood flow
    Breast pain and swelling during menses
    Pelvic pain during menses
    Irritable and depressed during menses
    Acne
    Facial hair growth
    Hair loss/thinning
  •   Never had Had it but dont' have it now Have it sometimes Have it always
    Hot Flashes
    Mental foginess
    Disinterest in sex
    Mood swings
    Depression
    Painful intercourse
    Shrinking breasts
    Facial hair growth
    Acne
    Increased vaginal pain, dryness or itching
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