Metabolic Assessment Form

Metabolic Assessment Form

Name:			Age:
Email:			Date:

Directions: Type in the number relating to the frequency of your symptoms
0 - Never/rarely
1 - Once per month or less
2 - Weekly or more than 4 times per month
3 - Daily or more than 3 times per week
Look for the areas with the highest percentage of symptoms, summarized in the chart

Colon Health
	Feeling that bowels do not empty completely
	Lower abdominal pain relieved by passing stool or gas
	Alternating constipation and diarrhea
	Diarrhea
	Constipation
	Hard, dry, or small stool
	Pass large amount of foul-smelling gas
	More than 3 bowel movements daily
	Use laxatives frequently
	TOTAL %

Intestinal Barrier Function
	Increasing frequency of food reactions
	Unpredictable food reactions
	Aches, pains, and swelling throughout the body
	Unpredictable abdominal swelling
	Frequent bloating and distention after eating
	TOTAL %

Loss of Immune Tolerance
	Intolerance to smells
	Intolerance to jewerly
	Intolerance to shampoo, lotion, detergents, etc.
	Multiple smell and chemical sensitivities
	Constant skin outbreaks
	TOTAL %

Stomach - Hypochlorhydria
	Excessive belching, burping, or bloating
	Gas immediately following a meal
	Offensive breath
	Difficult bowel movements
	Sense of fullness during and after meals
	Difficulty digesting proteins and meats
	Undigested food found in stools
	TOTAL %

Stomach - Acid Balance
	Stomach pain, burning, or aching 1-4 hours after eating
	Use of antacids
	Feel hungry an hour or two after eating
	Heartburn when lying down or bending forward
	Temporary relief by using antacids, food, milk, or carbonated beverages
	Digestive problems subside with rest or relaxation
	Hearburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
	TOTAL %

Pancreas Enzyme Deficiency
	Difficulty digesting roughage and fiber
	Indigestion and fullness last 2-4 hours after eating
	Pain, tenderness, soreness on left side under rib cage
	Excessive passage of gas
	Nausea and/or vomiting
	Stool undigested, foul smelling, mucus like, greasy, or poorly formed
	Frequent loss of appetite
	TOTAL %

Small Intestine Bacterial Overgrowth
	Abdominal distention after consumption of fiber, starches, and sugar
	Abdominal distention after certain probiotic or natural supplements
	Decreased gastrointestinal motility, constipation
	Increased gastrointestinal motility, diarrhea
	Suspicion of nutritional malabsorption
	Frequent use of antacid medication
	TOTAL %

Gall Bladder Deficiency
	Greasy or high-fat foods cause distress
	Lower bowel gas and/or bloating several hours after eating
	Bitter metallic taste in mouth, especially in the morning
	Burping, fishy taste after consuming fish oil
	Unexplained itchy skin
	Yellowish cast to eyes
	Stool color alternates from clay colored to normal brown
	Reddened skin, especially palms
	Dry or flaky skin and/or hair
	History of gallbladder attacks or stones
	TOTAL %

Liver Deficiency
	Acne and unhealthy skin
	Excessive hair loss
	Overall sense of bloating
	Body swelling for no reason
	Hormone imbalances
	Weight gain
	Poor bowel function
	Excessively foul-smelling sweat
	TOTAL %

Sugar Metabolism - Hypoglycemia
	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 tremors
	Agitated, easily upset, nervous
	Poor memory, forgetful between meals
	Blurred vision
	TOTAL %

Insulin Resistance - Utilization of Sugars
	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 appetite
	Difficulty losing weight
	TOTAL %

Adrenal Deficiency
	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
	TOTAL %

Adrenal Stress
	Cannot fall asleep easily
	Perspire easily
	Under a high amount fo stress
	Weight gain when under stress
	Wakeup tired even after 6 or more hours of sleep
	Excessive perspiration or perspiration with little or no activity
	TOTAL %

Electrolyte Imbalance
	Edema and swelling in ankles or wrists
	Muscle cramping
	Poor muscle endurance
	Frequent urination
	Frequent thirst
	Crave salt
	Abnormal sweating from minimal activity
	Change in bowel regularity
	Inability to hold breath for long periods
	Shallow, rapid breathing
	TOTAL %

Hypothyroid Function
	Tired/sluggish
	Feel cold - hands, feet, all over
	Require excess amounts of sleep to function properly
	Increase in weight 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 excessive hair loss
	Dryness of skin and/or scalp
	Mental sluggishness
	TOTAL %

Hyperthyroid Function
	Heart palpitations
	Inward trembling
	Increased pulse even at rest
	Nervous and emotional
	Insomnia
	Night sweats
	Difficulty gaining weight
	TOTAL %

Summary of Scores		Percentage
Colon Health
Intestinal Barrier Function
Loss of Immune Tolerance
Stomach - Hypochlorhydria
Stomach - Acid Balance
Pancreas Enzyme Deficiency
Small Intestine Bacterial Overgrowth
Gall Bladder Deficiency
Liver Deficiency
Sugar Metabolism - Hypoglycemia
Insulin Resistance - Utilization of Sugars
Adrenal Deficiency
Adrenal Stress
Electrolyte Imbalance
Hypothyroid Function
Hyperthyroid Function