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Metabolic Survey
First Name
*
Last Name
*
Email
*
Age
*
Sex
*
Male
Female
Date
Please list any health concerns in your order of importance
*
1
2
3
4
5
Category 1
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Feeling that bowels do not empty completely
*
0
1
2
3
Lower abdominal pain relief 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, and/or small stool
*
0
1
2
3
Coated tongue or "fuzzy" debris on tongue
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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 2
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
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 movements
*
0
1
2
3
Sense of fullness during and after meals
*
0
1
2
3
Difficulty digesting fruits and vegatables; undigested foods found in stool
*
0
1
2
3
Category 3
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Stomach pain, burning, or aching 1-4 hours after eating
*
0
1
2
3
Do you frequently use antiacids?
*
0
1
2
3
Feeling hungry an hour or two after eating
*
0
1
2
3
Heartburn when lying down or bending forward
*
0
1
2
3
Temporary relief from antiacids, food, milk, carbonated beverages
*
0
1
2
3
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
*
0
1
2
3
Category 4
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Roughage and fiber cause constipation
*
0
1
2
3
Indigestion and fullness last 2-4 hours after eating
*
0
1
2
3
Pain, tenderness, and/or 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, and/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 5
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Greasy or high fat foods cause distress
*
0
1
2
3
Lower bowel gas and or bloating serveral 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 6
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Crave sweets during the day
*
0
1
2
3
Irritable if meals are missed
*
0
1
2
3
Depend on coffee to keep yourself going or get started
*
0
1
2
3
Get lightheaded if meals are missed
*
0
1
2
3
Eating relieves fatigue
*
0
1
2
3
Feel shaky, jittery, and/or tremors
*
0
1
2
3
Agitated, easily upset, nervous
*
0
1
2
3
Poor memory, forgetful
*
0
1
2
3
Blurred vision
*
0
1
2
3
Category 7
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Fatigue after meals
*
0
1
2
3
Eating sweets does not relieve cravings for sugar
*
0
1
2
3
Must have sweets after meals
*
0
1
2
3
Waist girth is equal or larger than hip girth
*
0
1
2
3
Having Frequent Urination
*
0
1
2
3
Having Increased Thirst & Appetite
0
1
2
3
Having difficulty losing weight
0
1
2
3
Category 8
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
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 9
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Cannot fall asleep
*
0
1
2
3
Perspire easily
*
0
1
2
3
Under high amounts 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 perspire with little to no activity
*
0
1
2
3
Category 10
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Tired, sluggish
*
0
1
2
3
Feel cold; hands, feet, and/or all over
*
0
1
2
3
Require excessive amounts of sleep to function properly
*
0
1
2
3
Increase in weight gain 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, and/or genitals or excessive falling hair
*
0
1
2
3
Dryness of skin and/or scalp
*
0
1
2
3
Mental sluggishness
*
0
1
2
3
Category 11
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Heart palpations
*
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 12
Please select the appropriate number "0-3" on all questions below. 0 being least/never to 3 being most/always
Diminished sex drive
*
0
1
2
3
Increased ability to eat sugars withouth symptoms
*
0
1
2
3
Goals & Success
What are your specific goals?
*
Complete the statement: "I will be overjoyed with my results when I can..."
*
