PATIENT EVALUATION FORM
Full Name
*
First Name
Last Name
Address
*
Street Address
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Mobile Phone
*
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email Address
*
Employer
# of hours worked per week:
Gender
*
Male
Female
# of Children:
Marital Status
*
Please Select
Married
Single
Widowed
Divorced
Spouse's Name:
First Name
Last Name
Emergency Contact:
*
First Name
Last Name
Emergency Contact Number
*
-
Area Code
Phone Number
Reason for your visit
*
How did you hear about us?
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DIAGNOSTIC EVALUATION
Have you been diagnosed with Diabetes?
*
Yes
No
If yes, are you on medication? List here:
Have you been diagnosed with Thyroid Disease/Disorder?
*
Yes
No
If yes, are you on medication? List here:
Have you been diagnosed with Autoimmune Disease?
*
Yes
No
If yes, please explain:
Do you currently have or ever had any issues with your digestion or bowel elimination?
*
Yes
No
If yes, please explain:
ADDITIONAL INFORMATION
Any additional medication(s):
Any additional supplement(s):
Number of Bowel Movements Daily:
*
# Hours of Sleep:
*
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Next
METABOLIC ASSESSMENT FORM
NAME:
*
First
Last
GENDER TYPE:
*
Male
Female
AGE:
*
PART I
Please list up to (5) major health concerns, in order of importance:
1.
*
2.
*
3.
*
4.
5.
PART II
Please use this scale to rate your answers: 0 = Never 1 = Sometimes 2 = Very often 3 = Always
CATEGORY I
Feeling that bowels do not empty completely
*
0
1
2
3
Lower abdominal pain relieved 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
Increasing frequency of food reactions
*
0
1
2
3
Unpredictable food reactions
*
0
1
2
3
Aches, pains, and swelling throughout the body
*
0
1
2
3
Unpredictable abdominal swelling
*
0
1
2
3
Frequent bloating and distention after eating
*
0
1
2
3
Abdominal intolerance to sugars and starches
*
0
1
2
3
CATEGORY III
Intolerance to smells
*
0
1
2
3
Intolerance to jewelry
*
0
1
2
3
Intolerance to shampoo, lotion, detergents, etc.
*
0
1
2
3
Multiple smell and chemical sensitivities
*
0
1
2
3
Constant skin outbreaks
*
0
1
2
3
CATEGORY IV
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 movement
*
0
1
2
3
Sense of fullness during and after meals
*
0
1
2
3
Difficulty digesting fruits and vegetables; undigested food found in stools
*
0
1
2
3
CATEGORY V
Stomach pain, burning, or aching 1-4 hours after eating
*
0
1
2
3
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 using antacids, food, milk or carbonated beverages
*
0
1
2
3
Digestive problems subside with rest and relaxation
*
0
1
2
3
Heartburn due to spicy food, chocolate, citrus, peppers, alcohol and caffeine
*
0
1
2
3
CATEGORY VI
Roughage and fiber cause constipation
*
0
1
2
3
Indigestion and fullness last 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 VII
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 VIII
Acne and unhealthy skin
*
0
1
2
3
Excessive hair loss
*
0
1
2
3
Overall sense of bloating
*
0
1
2
3
Bodily swelling for no reason
*
0
1
2
3
Hormone imbalances
*
0
1
2
3
Weight gain
*
0
1
2
3
Poor bowel function
*
0
1
2
3
Excessively foul-smelling sweat
*
0
1
2
3
CATEGORY IX
Crave sweets during the day
*
0
1
2
3
Irritable if meals are missed
*
0
1
2
3
Depend on coffee to keep going/get started
*
0
1
2
3
Get light-headed if meals are missed
*
0
1
2
3
Eating relieves fatigue
*
0
1
2
3
Feel shaky, jittery or have tremors
*
0
1
2
3
Agitated, easily upset or nervous
*
0
1
2
3
Poor memory/forgetful
*
0
1
2
3
Blurred vision
*
0
1
2
3
CATEGORY X
Fatigue after meals
*
0
1
2
3
Crave sweets duting the day
*
0
1
2
3
Eating sweets does not relieve cravings for sugar
*
0
1
2
3
Must have sweets after meal
*
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 XI
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 XII
Cannot fall asleep
*
0
1
2
3
Perspire easily
*
0
1
2
3
Under high amount 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 XIII
Edema and swelling in ankles and wrists
*
0
1
2
3
Muscle cramping
*
0
1
2
3
Poor muscle endurance
*
0
1
2
3
Frequent urination
*
0
1
2
3
Frequent thirst
*
0
1
2
3
Crave salt
*
0
1
2
3
Abnormal sweating from minimal activity
*
0
1
2
3
Alteration in bowel regularity
*
0
1
2
3
Inability to hold breath for long periods
*
0
1
2
3
Shallow, rapid breathing
*
0
1
2
3
CATEGORY XIV
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 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, or genitals, or excessive hair loss
*
0
1
2
3
Dryness of skin and/or scalp
*
0
1
2
3
Mental sluggishness
*
0
1
2
3
CATEGORY XV
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 XVI
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 XVII
Increased sex drive
*
0
1
2
3
Tolerance to sugars reduced
*
0
1
2
3
"Splitting" type headaches
*
0
1
2
3
CATEGORY XVIII - (Males only)
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 emptying
0
1
2
3
Leg twitching at night
0
1
2
3
CATEGORY XIX - (Males only)
Decreased libido
0
1
2
3
Decreased number of spontaneous morning erections
0
1
2
3
Decreased fullness of erections
0
1
2
3
Difficulty maintaining 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
Decreased 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 XX - (Menstruating Females Only)
Do you still have a menstual cycle?
Yes
No
Perimenopausal
Yes
No
Alternating menstrual cycle lengths
Yes
No
Extended menstrual cycle (greater than 32 days)
Yes
No
Shortened menstrual cycle (less than 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
0
1
2
3
Facial hair growth
0
1
2
3
Hair loss/thinning
0
1
2
3
CATEGORY XXI - (Menopausal Females Only)
How many years have you been 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
Increase vaginal pain, dryness, or itching
0
1
2
3
Part III
How many alcoholic beverages do you consume per week?
*
How many caffeinated beverages do you consume daily?
*
On a scale 1-10, rate your stress level for an average week:
*
How many times do you eat fish per week?
*
How many times do you eat out per week?
*
How many times do you exercise per week?
*
How many times do you eat raw nuts or seeds per week?
*
List the (3) worst foods you eat during the average week:
*
List the (3) healthiest foods you eat during the average week:
*
Enter the message as it's shown
*
Submit
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