Name: ___________________________________________ Age: ______ Sex: _____ Date: ______________ PART I Please list your 5 major health concerns in order of importance:1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________3. __________________________________________________________________________________________4. __________________________________________________________________________________________5. __________________________________________________________________________________________

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

Metabolic Assessment Form

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

Category I Feelingthatbowelsdonotemptycompletely LowerabdominalpainrelievedbypassingstoolorgasAlternatingconstipationanddiarrhea DiarrheaConstipationHard,dry,orsmallstoolCoatedtongueor“fuzzy”debrisontonguePasslargeamountoffoul-smellinggasMorethan3bowelmovementsdailyUselaxativesfrequently

Category II IncreasingfrequencyoffoodreactionsUnpredictablefoodreactionsAches,pains,andswellingthroughoutthebodyUnpredictableabdominalswellingFrequentbloatinganddistentionaftereating Abdominalintolerancetosugarsandstarches Category III IntolerancetosmellsIntolerancetojewelryIntolerancetoshampoo,lotion,detergents,etc.MultiplesmellandchemicalsensitivitiesConstantskinoutbreaks Category IV Excessivebelching,burping,orbloatingGasimmediatelyfollowingamealOffensivebreathDifficultbowelmovementSenseoffullnessduringandaftermealsDifficultydigestingfruitsandvegetables; undigestedfoodfoundinstools

Category VStomachpain,burning,oraching1-4hoursaftereatingUseantacidsFeelhungryanhourortwoaftereatingHeartburnwhenlyingdownorbendingforwardTemporaryreliefbyusingantacids,food,milk,or carbonatedbeveragesDigestiveproblemssubsidewithrestandrelaxationHeartburnduetospicyfoods,chocolate,citrus, peppers,alcohol,andcaffeine

Category VI RoughageandfibercauseconstipationIndigestionandfullnesslast2-4hoursaftereatingPain,tenderness,sorenessonleftsideunderribcageExcessivepassageofgas

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

Category VI (continued)Nauseaand/orvomitingStoolundigested,foulsmelling,mucouslike, greasy,orpoorlyformedFrequenturinationIncreasedthirstandappetite

Category VII Greasyorhigh-fatfoodscausedistressLowerbowelgasand/orbloatingseveralhours aftereatingBittermetallictasteinmouth,especiallyinthemorningBurpy,fishytasteafterconsumingfishoilsDifficultylosingweightUnexplaineditchyskinYellowishcasttoeyesStoolcoloralternatesfromclaycoloredto normalbrownReddenedskin,especiallypalmsDryorflakyskinand/orhairHistoryofgallbladderattacksorstonesHaveyouhadyourgallbladderremoved?

Category VIIIAcneandunhealthyskinExcessivehairlossOverallsenseofbloatingBodilyswellingfornoreasonHormoneimbalancesWeightgainPoorbowelfunctionExcessivelyfoul-smellingsweat

Category IX CravesweetsduringthedayIrritableifmealsaremissedDependoncoffeetokeepgoing/getstartedGetlight-headedifmealsaremissedEatingrelievesfatigueFeelshaky,jittery,orhavetremorsAgitated,easilyupset,nervousPoormemory/forgetfulBlurredvision

Category XFatigueaftermealsCravesweetsduringthedayEatingsweetsdoesnotrelievecravingsforsugarMusthavesweetsaftermealsWaistgirthisequalorlargerthanhipgirthFrequenturinationIncreasedthirstandappetiteDifficultylosingweight

0 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)

PART IIIHowmanyalcoholicbeveragesdoyouconsumeperweek?Howmanycaffeinatedbeveragesdoyouconsumeperday?Howmanytimesdoyoueatoutperweek?Howmanytimesdoyoueatrawnutsorseedsperweek?Listthethreeworstfoodsyoueatduringtheaverageweek:Listthethreehealthiestfoodsyoueatduringtheaverageweek:PART IVPlease list any medications you currently take and for what conditions:

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

Category XI CannotstayasleepCravesaltSlowstarterinthemorningAfternoonfatigueDizzinesswhenstandingupquicklyAfternoonheadachesHeadacheswithexertionorstressWeaknails

Category XIICannotfallasleepPerspireeasilyUnderhighamountofstressWeightgainwhenunderstressWakeuptiredevenafter6ormorehoursofsleepExcessiveperspirationorperspirationwithlittle ornoactivity

Category XIII EdemaandswellinginanklesandwristsMusclecrampingPoormuscleenduranceFrequenturinationFrequentthirstCravesaltAbnormalsweatingfromminimalactivityAlterationinbowelregularityInabilitytoholdbreathforlongperiodsShallow,rapidbreathing

Category XIVTired/sluggishFeelcold―hands,feet,alloverRequireexcessiveamountsofsleeptofunctionproperlyIncreaseinweightevenwithlow-caloriedietGainweighteasilyDifficult,infrequentbowelmovementsDepression/lackofmotivationMorningheadachesthatwearoffasthedayprogressesOuterthirdofeyebrowthinsThinningofhaironscalp,face,orgenitals,orexcessive hairlossDrynessofskinand/orscalpMentalsluggishness

Category XVHeartpalpitationsInwardtremblingIncreasedpulseevenatrestNervousandemotionalInsomniaNightsweatsDifficultygainingweight

Category XVIDiminishedsexdriveMenstrualdisordersorlackofmenstruationIncreasedabilitytoeatsugarswithoutsymptoms

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

Category XVII IncreasedsexdriveTolerancetosugarsreduced“Splitting”-typeheadaches

Category XVIII (Males Only)UrinationdifficultyordribblingFrequenturinationPaininsideoflegsorheelsFeelingofincompletebowelemptyingLegtwitchingatnight

Category XIX (Males Only)DecreasedlibidoDecreasednumberofspontaneousmorningerectionsDecreasedfullnessoferectionsDifficultymaintainingmorningerectionsSpellsofmentalfatigueInabilitytoconcentrateEpisodesofdepressionMusclesorenessDecreasedphysicalstaminaUnexplainedweightgainIncreaseinfatdistributionaroundchestandhipsSweatingattacksMoreemotionalthaninthepast

Category XX (Menstruating Females Only)PerimenopausalAlternatingmenstrualcyclelengthsExtendedmenstrualcycle(greaterthan32days)Shortenedmenstrualcycle(lessthan24days)PainandcrampingduringperiodsScantybloodflowHeavybloodflowBreastpainandswellingduringmensesPelvicpainduringmensesIrritableanddepressedduringmensesAcneFacialhairgrowthHairloss/thinning

Category XXI (Menopausal Females Only)Howmanyyearshaveyoubeenmenopausal?Sincemenopause,doyoueverhaveuterinebleeding?HotflashesMentalfogginessDisinterestinsexMoodswingsDepressionPainfulintercourseShrinkingbreastsFacialhairgrowthAcneIncreasedvaginalpain,dryness,oritching

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)

Rateyourstresslevelonascaleof1-10duringtheaverageweek:Howmanytimesdoyoueatfishperweek?Howmanytimesdoyouworkoutperweek?