Metabolic Assessment Form

This form helps determine the patient's current metabolic condition for evaluation. The information in this form should be filled out completely and accurately to the best of your understanding. The information in this form is confidential and is for use by your doctor only. Do not exit the page or leave the form before submitting the information. If you refresh or leave the page, you will need to start over.

6035 Shallowford Rd Suite 101
Chattanooga, TN 37421
OFFICE 423-499-0003 | FAX 423-485-7992

Today's Date(Required)

MM slash DD slash YYYY

Patient Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

MaleFemale

Please list the 5 major health concerns in your order of importance:

1.

2.

3.

4.

5.

Please complete the following questions:

Select the appropriate answer in the range between 0 (least or never) and 3 (most or always).

Category I - Colon Health

Feeling that bowels do not empty completely

0

1

2

3

Lower abdominal pain relief by passing stool or gas

0

1

2

3

Alternating constipation and diarrhea

0

1

2

3

Diarrhea

0

1

2

3

Constipation

0

1

2

3

Hard, dry, or small stool

0

1

2

3

Coated tongue or "fuzzy" debris on tongue

0

1

2

3

Pass large amount of foul smelling gas

0

1

2

3

More than 3 bowel movements daily

0

1

2

3

Use laxatives frequently

0

1

2

3

Category II - Hypochlorhydria

Excessive belching, burping, or bloating

0

1

2

3

Gas immediately following a meal

0

1

2

3

Offensive breath

0

1

2

3

Difficult bowel movements

0

1

2

3

Sense of fullness during and after meals

0

1

2

3

Difficulty digesting fruits and vegetables, undigested foods found in stools

0

1

2

3

Category III - Hyperacidity

Stomach pain, burning, or aching 1-4 hours after eating

0

1

2

3

Regularly use antacids

0

1

2

3

Feel hungry an hour or two after eating

0

1

2

3

Heartburn when lying down or bending forward

0

1

2

3

Temporary relief from antacids, food, milk, carbonated beverages

0

1

2

3

Digestive problems subside with rest and relaxation

0

1

2

3

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

0

1

2

3

Category IV - Small intestine health

Roughage and fiber cause constipation

0

1

2

3

Indigestion and fullness lasts 2-4 hours after eating

0

1

2

3

Pain, tenderness, soreness on left side under rib cage

0

1

2

3

Excessive passage of gas

0

1

2

3

Nausea and/or vomiting

0

1

2

3

Stool undigested, foul smelling, mucous-like, greasy, or poorly formed

0

1

2

3

Frequent urination

0

1

2

3

Increased thirst and appetite

0

1

2

3

Difficulty losing weight

0

1

2

3

Category V - Biliary tract health

Greasy or high-fat foods cause distress

0

1

2

3

Lower bowel gas and or bloating several hours after eating

0

1

2

3

Bitter metallic taste in mouth, especially in the morning

0

1

2

3

Unexplained itchy skin

0

1

2

3

Yellowish cast to eyes

0

1

2

3

Stool color alternates from clay colored to normal brown

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

0

1

2

3

Have you had your gallbladder removed

Yes

No

Category VI - Hypoglycemia

Crave sweets during the day

0

1

2

3

Irritable if meals are missed

0

1

2

3

Depend on coffee to keep yourself going or started

0

1

2

3

Get lightheaded if meals are missed

0

1

2

3

Eating relieves fatigue

0

1

2

3

Feel shaky, jittety, or have tremors

0

1

2

3

Agitated, easily upset, nervous

0

1

2

3

Poor memory/forgetful

0

1

2

3

Blurred vision

0

1

2

3

Category VII - Insulin resistance

Fatigue after meals

0

1

2

3

Crave sweets during the day

0

1

2

3

Eating sweets does not relieve cravings for sugar

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

Frequent urination

0

1

2

3

Increased thirst and appetite

0

1

2

3

Difficulty losing weight

0

1

2

3

Category VIII - Adrenal fatigue

Cannot stay asleep

0

1

2

3

Crave salt

0

1

2

3

Slow starter in the morning

0

1

2

3

Afternoon fatigue

0

1

2

3

Dizziness when standing up quickly

0

1

2

3

Afternoon headaches

0

1

2

3

Headaches with exertion or stress

0

1

2

3

Weak nails

0

1

2

3

Category IX - Adrenal hyperfunction

Cannot fall asleep

0

1

2

3

Perspire easily

0

1

2

3

Perspire easily under high amounts of stress

0

1

2

3

Weight gain when under stress

0

1

2

3

Wake up tired even after 6 or more hours of sleep

0

1

2

3

Excessive perspiration or perspiration with little or no activity

0

1

2

3

Category X - Hypothyroid

Tired, sluggish

0

1

2

3

Feel cold; hands, feet, all over

0

1

2

3

Require excessive amounts of sleep to function properly

0

1

2

3

Increase in weight gain even with low-calorie diet

0

1

2

3

Gain weight easily

0

1

2

3

Difficult, infrequent bowel movements

0

1

2

3

Depression, lack of motivation

0

1

2

3

Morning headaches that wear off as the day progresses

0

1

2

3

Outer third of eyebrow thins

0

1

2

3

Thinning of hair on scalp, face, genitals or excessive falling hair

0

1

2

3

Dryness of skin and/or scalp

0

1

2

3

Mental sluggishness

0

1

2

3

Category XI - Thyroid hyperfunction

Heart palpitations

0

1

2

3

Inward trembling

0

1

2

3

Increased pulse even at rest

0

1

2

3

Nervous and emotional

0

1

2

3

Insomnia

0

1

2

3

Night sweats

0

1

2

3

Difficulty gaining weight

0

1

2

3

Category XII - Pituitary hypofunction

Diminished sex drive

0

1

2

3

Menstrual disorders or lack of menstruation

0

1

2

3

Increased ability to eat sugars without symptoms

0

1

2

3

Category XIII - Pituitary hyperfunction

Increased sex drive

0

1

2

3

Tolerance to sugars reduced

0

1

2

3

"Splitting" type headaches

0

1

2

3

Category XIV - (Males only) Prostate health

Urination difficulty or dribbling

0

1

2

3

Frequent urination

0

1

2

3

Pain inside of legs or heels

0

1

2

3

Feeling of incomplete bowel evacuation.

0

1

2

3

Leg nervousness at night

0

1

2

3

Category XV - (Males only) Andropause

Decrease in libido

0

1

2

3

Decrease in spontaneous morning erections

0

1

2

3

Decrease in fullness of erections

0

1

2

3

Difficulty in maintain morning erections

0

1

2

3

Spells of mental fatigue

0

1

2

3

Inability to concentrate

0

1

2

3

Episodes of depression

0

1

2

3

Muscle soreness

0

1

2

3

Decrease in physical stamina

0

1

2

3

Unexplained weight gain

0

1

2

3

Increase in fat distribution around chest and hips

0

1

2

3

Sweating attacks

0

1

2

3

More emotional than in the past

0

1

2

3

Category XVI - (Menstruating Females only)

Are you perimenopausal

Yes

No

Alternating menstrual cycle lengths

Yes

No

Extended menstrual cycle, greater than 32 days

Yes

No

Extended menstrual cycle, greater than 32 days

Yes

No

Shortened menses, less than every 24 days

Yes

No

Pain and cramping during periods

0

1

2

3

Scanty blood flow

0

1

2

3

Heavy blood flow

0

1

2

3

Breast pain and swelling during menses

0

1

2

3

Pelvic pain during menses

0

1

2

3

Irritable and depressed during menses

0

1

2

3

Acne breakouts

0

1

2

3

Facial hair growth

0

1

2

3

Hair loss/thinning

0

1

2

3

Category XVII - (Menopausal Females only)

Number of years menopausal?

Since menopause, do you ever have uterine bleeding?

Yes

No

Hot flashes

0

1

2

3

Mental fogginess

0

1

2

3

Disinterest in sex

0

1

2

3

Mood swings

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

Overall health activities

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times a week do you eat raw nuts or seeds?

How many times a week do you eat fish?

How many times a week do you workout?

Do you smoke?

Yes

No

If you smoke, how many times per day?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress levels on a scale of 1-10 during the average week:

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

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