New Patient Application

Metabolic Assessment Form

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

1)
2)
3)
4)
5)

PART II
Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

0123     Feeling that bowels do not empty completely
0123     Lower abdominal pain relieved by passing stool or gas
0123     Alternating constipation and diarrhea
0123     Diarrhea
0123     Constipation
0123     Hard, dry, or small stool
0123     Coated tongue or "fuzzy" debris on tongue
0123     Pass large amount of foul-smelling gas
0123     More than 3 bowel movements daily
0123     Use laxatives frequently

Category II

0123     Increasing frequency of food reactions
0123     Unpredictable food reactions
0123     Aches, pains, and swelling throughout the body
0123     Unpredictable abdominal swelling
0123     Frequent bloating and distention after eating
0123     Abdominal intolerance to sugars and starches

Category III

0123     Intolerance to smells
0123     Intolerance to jewelry
0123     Intolerance to shampoo, lotion, detergents, etc.
0123     Multiple smell and chemical sensitivities
0123     Constant skin outbreaks

Category IV

0123     Excessive belching, burping, or bloating
0123     Gas immediately following a meal
0123     Offensive breath
0123     Difficult bowel movement
0123     Sense of fullness during and after meals
0123     Difficulty digesting fruits and vegetables; undigested food found in stools

Category V

0123     Stomach pain, burning, or aching 1-4 hours after eating
0123     Use antacids
0123     Feel hungry an hour or two after eating
0123     Heartburn when lying down or bending forward
0123     Temporary relief by using antacids, food, milk, or carbonated beverages
0123     Digestive problems subside with rest and relaxation
0123     Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category VI

0123     Roughage and fiber cause constipation
0123     Indigestion and fullness last 2-4 hours after eating
0123     Pain, tenderness, soreness on left side under rib cage
0123     Excessive passage of gas
0123     Nausea and/or vomiting
0123     Stool undigested, foul smelling, mucous like, greasy, or poorly formed
0123     Frequent urination
0123     Increased thirst and appetite

Category VII

0123     Greasy or high-fat foods cause distress
0123     Lower bowel gas and/or bloating several hours after eating
0123     Bitter metallic taste in mouth, especially in the morning
0123     Burpy, fishy taste after consuming fish oils
0123     Difficulty losing weight
0123     Unexplained itchy skin
0123     Yellowish cast to eyes
0123     Stool color alternates from clay colored to normal brown
0123     Reddened skin, especially palms
0123     Dry or flaky skin and/or hair
0123     History of gallbladder attacks or stones
YesNo     Have you had your gallbladder removed?

Category VIII

0123     Acne and unhealthy skin
0123     Excessive hair loss
0123     Overall sense of bloating
0123     Bodily swelling for no reason
0123     Hormone imbalances
0123     Weight gain
0123     Poor bowel function
0123     Excessively foul-smelling sweat

Category IX

0123     Crave sweets during the day
0123     Irritable if meals are missed
0123     Depend on coffee to keep going/get started
0123     Get light-headed if meals are missed
0123     Eating relieves fatigue
0123     Feel shaky, jittery, or have tremors
0123     Agitated, easily upset, nervous
0123     Poor memory/forgetful
0123     Blurred vision

Category X

0123     Fatigue after meals
0123     Crave sweets during the day
0123     Eating sweets does not relieve cravings for sugar
0123     Must have sweets after meals
0123     Waist girth is equal or larger than hip girth
0123     Frequent urination
0123     Increased thirst and appetite
0123     Difficulty losing weight

Category XI

0123     Cannot stay asleep
0123     Crave salt
0123     Slow starter in the morning
0123     Afternoon fatigue
0123     Dizziness when standing up quickly
0123     Afternoon headaches
0123     Headaches with exertion or stress
0123     Weak nails
*** Make sure you complete the questions in the right column. ***

Category XII

0123     Cannot fall asleep
0123     Perspire easily
0123     Under high amount of stress
0123     Weight gain when under stress
0123     Wake up tired even after 6 or more hours of sleep
0123     Excessive perspiration or perspiration with little or no activity

Category XIII

0123     Edema and swelling in ankles and wrists
0123     Muscle cramping
0123     Poor muscle endurance
0123     Frequent urination
0123     Frequent thirst
0123     Crave salt
0123     Abnormal sweating from minimal activity
0123     Alteration in bowel regularity
0123     Inability to hold breath for long periods
0123     Shallow, rapid breathing

Category XIV

0123     Tired/sluggish
0123     Feel cold?hands, feet, all over
0123     Require excessive amounts of sleep to function properly
0123     Increase in weight even with low-calorie diet
0123     Gain weight easily
0123     Difficult, infrequent bowel movements
0123     Depression/lack of motivation
0123     Morning headaches that wear off as the day progresses
0123     Outer third of eyebrow thins
0123     Thinning of hair on scalp, face, or genitals, or excessive hair loss
0123     Dryness of skin and/or scalp
0123     Mental sluggishness

Category XV

0123     Heart palpitations
0123     Inward trembling
0123     Increased pulse even at rest
0123     Nervous and emotional
0123     Insomnia
0123     Night sweats
0123     Difficulty gaining weight

Category XVI

0123     Diminished sex drive
0123     Menstrual disorders or lack of menstruation
0123     Increased ability to eat sugars without symptoms

Category XVII

0123     Increased sex drive
0123     Tolerance to sugars reduced
0123     "Splitting" - type headaches

Sex & Status * required

Category XVIII (Males Only)

0123     Urination difficulty or dribbling
0123     Frequent urination
0123     Pain inside of legs or heels
0123     Feeling of incomplete bowel emptying
0123     Leg twitching at night

Category XIX (Males Only)

0123     Decreased libido
0123     Decreased number of spontaneous morning erections
0123     Decreased fullness of erections
0123     Difficulty maintaining morning erections
0123     Spells of mental fatigue
0123     Inability to concentrate
0123     Episodes of depression
0123     Muscle soreness
0123     Decreased physical stamina
0123     Unexplained weight gain
0123     Increase in fat distribution around chest and hips
0123     Sweating attacks
0123     More emotional than in the past

Category XX (Menstruating Females Only)

YesNo     Perimenopausal
YesNo     Alternating menstrual cycle lengths
YesNo     Extended menstrual cycle (greater than 32 days)
YesNo     Shortened menstrual cycle (less than 24 days)
0123     Pain and cramping during periods
0123     Scanty blood flow
0123     Heavy blood flow
0123     Breast pain and swelling during menses
0123     Pelvic pain during menses
0123     Irritable and depressed during menses
0123     Acne
0123     Facial hair growth
0123     Hair loss/thinning

Category XXI (Menopausal Females Only)

    How many years have you been menopausal?
YesNo     Since menopause, do you ever have uterine bleeding?
0123     Hot flashes
0123     Mental fogginess
0123     Disinterest in sex
0123     Mood swings
0123     Depression
0123     Painful intercourse
0123     Shrinking breasts
0123     Facial hair growth
0123     Acne
0123     Increased vaginal pain, dryness, or itching

PART III

How many alcoholic beverages do you consume per week?
Rate your stress level on a scale of 1-10 during the average week:
How many caffeinated beverages do you consume per day?
How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work out per week?
How many times do you eat raw nuts or seeds 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 IV

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

Patient Information

Please fill out the following form in as much detail as possible. All your health information is kept confidential.

Name:
Address:
City:
State:
ZIP:
Date of Birth:
Sex:
# Kids:
Height:
Weight:
Status:
SingleMarriedPartneredDivorcedWidowedMinor
Occupation:
Employer/School:
Cell Phone:
Email:
Preferred contact method:
Cell PhoneWork PhoneEmail
Spouse/Partner's Name:
Who Referred You?

In case of emergency please contact:

Name:
Relationship:
Home Phone:
Other Phone:

Patient Condition

What is your major complaint? (be as specific as possible)
When did you condition/symptoms/pain first appear? (specific date, days ago, weeks, ago, etc.)
Is this condition getting progressively worse? YesNoConstantComes & goes
When is it worse? MorningAfternoonEveningChanges time of day
Does it interfere with:
WorkSleepDaily RoutinesRecreationOther (fill in text box below)
Other description:
How long has it been since you really felt good?
Other doctors seen for this condition: MDDCDODDSOther (fill in text box below)
Other description:
Does the condition/symptom/pain radiate? YesNo
If yes, where and how frequently:
How long/often does the radiation occur/last?
Do you have: NumbnessTinglingWeaknessNone of these
Describe above selections:
List your body part condition/symptoms/pain & rating # on the scale below 0 (none) - 10 (severe):
Body part:
Severity:
Body part:
Severity:
Body part:
Severity:
Type of pain:
SharpDullThrobbingTinglingShootingBurningAchingNumbness
What activities or positions aggravate your condition?
BendingCoughingGetting up/downDrivingLiftingLying downSneezingStandingStraining at stoolTurning headTwistingWalking
What activities or positions relieve your condition:
HeatLying downIceMedicationSittingMassageSittingStandingStretchingExercise
Have you ever had this condition before? YesNo
If yes, when?
Were you treated for this condition or a similar one before? YesNo
If yes, when/by whom?

Health History

Do you have any allergies? (food, contact, environmental)
List any prescribed medications, over the counter medications, vitamins, herbs and supplements:
When was your last:
Physical exam:
Blood/lab work:
X-ray study:
Injuries/Surgeries you’ve had and when:
Have you had or do you have any of the following conditions or diseases?
Ankylosing spondulitisAnxietyArthritisAsthmaBleeding disorderBlurred visionBowel/Bladder problemsBuzzing in earCancerCarpal tunnelCeliac disease (gluten)Chest painsChronic fatigueCold hands or feetColitis/discerticulitisCompression fracturesConnective tissue issuesCOPD (bronchitis/emphy)DepressionDiabetesDigestive/bowel problemsDizziness or vertigoFibromyalgiaFusions (spinal, joint)GoutHear diseaseHepatitis (A, B, C, etc.)HerpesHigh blood pressureHip replacementHIV/AIDSKidney diseaseKnee surgeryLiver diseaseMarfan syndromeMultiple sclerosisOsteoporosis/peniaParkinson’s diseaseRotator cuff problemSTI/STDShoulder surgerySpinal surgeryStroke/TIAThyroid problemsTuberculosis
Other:
Other:
Are there any conditions that run in your family? YesNo
If yes, what & who?

Personal and Social Health History

Are you currently pregnant, or do you think you may be pregnant? YesNo
If yes, how many weeks?
How many hours per week do you typically work/attend school?
<2020304040+
What are your typical duties and postures (sitting, standing, lifting, etc.)?
Do you exercise? YesNo
If yes, how often and what type?
How would you rate your eating habits?
ExcellentPretty GoodCould be betterNeeds Improvement
How well do you sleep?
ExcellentPretty GoodRestlessCan't sleepWake up often
How many hours of sleep do you get daily?
Do you feel rested in the morning? YesNo
How is your energy overall?
Full powerOKLowSporadic/Generally fatiguedI depend on caffeine for energy
How do you feel your immune system is working?
StrongOKLow


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