Metabolic Assessment Form Step 1 of 8 12% Name* First Last Email* Age*Gender* Male Female HiddenAt which Revitalize Health location are you a patient? Sugar Land The Woodlands Date MM slash DD slash YYYY PART IPlease list your 5 major health concerns in order of importance:Concern #1 Concern #2 Concern #3 Concern #4 Concern #5 Part IIPlease select the appropriate number on all questions below. "0" indicates never/least frequent and "3" indicates always/most frequent:Category 1Feeling that bowels do not empty completely0123Lower abdominal pain relieved by passing stool or gas0123Alternating constipation and diarrhea0123Diarrhea0123Constipation0123Hard, dry, or small stool0123Coated tongue or "fuzzy" debris on tongue0123Pass large amount of foul-smelling gas0123More than 3 bowel movements daily0123Use laxatives daily0123Category IIIncreasing frequency of food reactions0123Unpredictable food reactions0123Aches, pains, and swelling throughout the body0123Unpredictable abdominal swelling0123Frequent bloating and distention after eating0123Abdominal intolerance to sugars and starches0123Category IIIIntolerance to smells0123Intolerance to jewelry0123Intolerance to shampoo, lotion, detergents, etc.0123Multiple smell and chemical sensitivities0123Constant skin outbreaks0123 Part II (continued)Please select the appropriate number on all questions below. "0" indicates never/least frequent and "3" indicates always/most frequent:Category IVExcessive belching, burping, or bloating0123Gas immediately following a meal0123Offensive breath0123Difficult bowel movement0123Sense of fullness during and after meals0123Difficulty digesting fruits and vegetables; undigested food found in stools0123Category VStomach pain, burning, or aching 1-4 hours after eating0123Use antacids0123Feel hungry an hour or two after eating0123Heartburn when lying down or bending forward0123Temporary relief by using antacids, food, milk, or carbonated beverages0123Digestive problems subside with rest and relaxation0123Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine0123Category VIRoughage and fiber cause constipation0123Indigestion and fullness last 2-4 hours after eating0123Pain, tenderness, soreness on left side under rib cage0123Excessive passage of gas0123Nausea and/or vomiting0123Stool undigested, foul smelling, mucous like, greasy, or poorly formed0123Frequent urination0123Increased thirst and appetite0123 Part II (continued)Please select the appropriate number on all questions below. "0" indicates never/least frequent and "3" indicates always/most frequent:Category VIIGreasy or high-fat foods cause distress0123Lower bowel gas and/or bloating several hours after eating0123Bitter metallic taste in mouth, especially in the morning0123Burpy, fishy taste after consuming fish oils0123Difficulty losing weight0123Unexplained itchy skin0123Yellowish cast to eyes0123Stool color alternates from clay colored to normal brown0123Reddened skin, especially palms0123Dry or flaky skin and/or hair0123History of gallbladder attacks or stones0123Have you had your gallbladder removed? Yes No Category VIIIAcne and unhealthy skin0123Excessive hair loss0123Overall sense of bloating0123Bodily swelling for no reason0123Hormone imbalances0123Weight gain0123Poor bowel function0123Excessively foul-smelling sweat0123Category IXCrave sweets during the day0123Irritable if meals are missed0123Depend on coffee to keep going/get started0123Get light-headed if meals are missed0123Eating relieves fatigue0123Feel shaky, jittery, or have tremors0123Agitated, easily upset, nervous0123Poor memory/forgetful0123Blurred vision0123 Part II (continued)Please select the appropriate number on all questions below. "0" indicates never/least frequent and "3" indicates always/most frequent:Category XFatigue after meals0123Crave sweets during the day0123Eating sweets does not relieve cravings for sugar0123Must have sweets after meals0123Waist girth is equal or larger than hip girth0123Frequent urination0123Increased thirst and appetite0123Difficulty losing weight0123Category XICannot stay asleep0123Crave salt0123Slow starter in the morning0123Afternoon fatigue0123Dizziness when standing up quickly0123Afternoon headaches0123Headaches with exertion or stress0123Weak nails0123Category XIICannot fall asleep0123Perspire easily0123Under high amount of stress0123Weight gain when under stress0123Wake up tired even after 6 or more hours of sleep0123Excessive perspiration or perspiration with little or no activity0123 Part II (continued)Please select the appropriate number on all questions below. "0" indicates never/least frequent and "3" indicates always/most frequent:Category XIIIEdema and swelling in ankles and wrists0123Muscle cramping0123Poor muscle endurance0123Frequent urination0123Frequent thirst0123Crave salt0123Abnormal sweating from minimal activity0123Alteration in bowel regularity0123Inability to hold breath for long periods0123Shallow, rapid breathing0123Category XIVTired/sluggish0123Feel cold--hands, feet, all over0123Require excessive amounts of sleep to function properly0123Increase in weight even with low-calorie diet0123Gain weight easily0123Difficult, infrequent bowel movements0123Depression/lack of motivation0123Morning headaches that wear off as the day progresses0123Outer third of eyebrow thins0123Thinning of hair on scalp, face, or genitals, or excessive hair loss0123Dryness of skin and/or scalp0123Mental sluggishness0123Category XVHeart palpitations0123Inward trembling0123Increased pulse even at rest0123Nervous and emotional0123Insomnia0123Night sweats0123Difficulty gaining weight0123 Part II (continued)Please select the appropriate number on all questions below. "0" indicates never/least frequent and "3" indicates always/most frequent:Category XVIDiminished sex drive0123Menstrual disorders or lack of menstruation0123Increased ability to eat sugars without symptoms0123Category XVIIIncreased sex drive0123Tolerance to sugars reduced0123"Splitting" - type headaches0123Category XVIIIUrination difficulty or dribbling0123Frequent urination0123Pain inside of legs or heels0123Feeling of incomplete bowel emptying0123Leg twitching at night0123Category XIXDecreased libido0123Decreased number of spontaneous morning erections0123Decreased fullness of erections0123Difficulty maintaining morning erections0123Spells of mental fatigue0123Inability to concentrate0123Episodes of depression0123Muscle soreness0123Decreased physical stamina0123Unexplained weight gain0123Increase in fat distribution around chest and hips0123Sweating attacks0123More emotional than in the past0123CATEGORY XVIII (Menstruating Females Only)If not applicable, skip down to Category XXIPerimenopausal Yes No Alternating menstrual cycle lengths Yes No Extended menstrual cycle lengths (greater than 32 days) Yes No Shortened menstrual cycle lengths (less than 24 days) Yes No Pain and cramping during periods0123Scanty blood flow0123Heavy blood flow0123Breast pain and swelling during menses0123Pelvic pain during menses0123Irritable and depressed during menses0123Acne0123Facial hair growth0123Hair loss/thinning0123CATEGORY XIX (Menopausal Females Only)If not applicable, skip to next pageHow many years have you been menopausal?Since menopause, do you ever have uterine bleeding? Yes No Hot flashes0123Mental fogginess0123Disinterested in sex0123Mood swings0123Depression0123Painful intercourse0123Shrinking breasts0123Facial hair growth0123Acne0123Increased vaginal pain, dryness, or itching0123 Part IIIHow many alcoholic beverages do you consume per week?How many caffeinated beverages do you consume per week?How many times do you eat out per week?How many times do you eat raw nuts or seeds per week?Rate your stress level on a scale of 1-10 during the average week:How many times do you eat fish per week?How many times do you work out per week?List the three worst foods you eat during the average week:List the three healthiest foods you eat during the average week:Part IVPlease list any medications you currently take and for what conditions:Please list any natural supplements you currently take and for what conditions:
