Home
Elite Services
Conditions
Concussions & Recovery
Injections
Athletes
Molecular Nutrition
Evaluations and testing
- Evaluation Information
Neurofeedback
Cognitive Therapy
Testimonials
Patient Center
About Us
Functional Vision Testing
Online Forms
Shockwave Therapy
Community Content

(972) 479-5179

Button Text

Call Today:

Home Metabolic Assessment

Metabolic Assessment

Name

Phone

Comments

Age

Sex Male Female

Date

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

Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely

Lower abdominal pain relief by passing stool or gas

Alternating constipation and diarrhea

Diarrhea

Constipation

Hard, dry, or small stool

Coated tongue of “fuzzy” debris on tongue

Pass large amount of foul smelling gas

More than 3 bowel movements daily

Use laxatives frequently

Category II

Excessive belching, burping, or bloating

Gas immediately following a meal

Offensive breath

Difficult bowel movements

Sense of fullness during and after meals

Difficulty digesting fruits and vegetables; undigested foods found in stools

Category III

Stomach pain, burning, or aching 1- 4 hours after eating

Use antacids

Feel hungry an hour or two after eating

Heartburn when lying down or bending forward

Temporary relief from antacids, food, milk, carbonated beverages

Digestive problems subside with rest and relaxation

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category IV

Roughage and fiber cause constipation

Indigestion and fullness lasts 2-4 hours after eating

Pain, tenderness, soreness on left side under rib cage

Excessive passage of gas

Nausea and/or vomiting

Stool undigested, foul smelling, mucous-like, greasy, or poorly formed

Frequent urination

Increased thirst and appetite

Difficulty losing weight

Category V

Greasy or high-fat foods cause distress

Lower bowel gas and or bloating several hours after eating

Bitter metallic taste in mouth, especially in the morning

Unexplained itchy skin

Yellowish cast to eyes

Stool color alternates from clay colored to normal brown

Reddened skin, especially palms

Dry or flaky skin and/or hair

History of gallbladder attacks or stones

Have you had your gallbladder removed Yes No

Category VI

Crave sweets during the day

Irritable if meals are missed

Depend on coffee to keep yourself going or started

Get lightheaded if meals are missed

Eating relieves fatigue

Feel shaky, jittery, or have tremors

Agitated, easily upset, nervous

Poor memory/forgetful

Blurred vision

Category VII

Fatigue after meals

Crave sweets during the day

Eating sweets does not relieve cravings for sugar

Must have sweets after meals

Waist girth is equal or larger than hip girth

Frequent urination

Increased thirst and appetite

Difficulty losing weight

Category VIII

Cannot stay asleep

Crave salt

Slow starter in the morning

Afternoon fatigue

Dizziness when standing up quickly

Afternoon headaches

Headaches with exertion or stress

Weak nails

Category IX

Cannot fall asleep

Perspire easily

Under high amounts of stress

Weight gain when under stress

Wake up tired even after 6 or more hours of sleep

Excessive perspiration or perspiration with little or no activity

Category X

Tired, sluggish

Feel cold – hands, feet, all over

Require excessive amounts of sleep to function properly

Increase in weight gain even with low-calorie diet

Gain weight easily

Difficult, infrequent bowel movements

Depression, lack of motivation

Morning headaches that wear off as the day progresses

Outer third of eyebrow thins

Thinning of hair on scalp, face, or genitals or excessive falling hair

Dryness of skin and/or scalp

Mental sluggishness

Category X

Heart palpitations

Inward trembling

Increased pulse even at rest

Nervous and emotional

Insomnia

Night sweats

Difficulty gaining weight

Category XII

Diminished sex drive

Menstrual disorders or lack of menstruation

Increased ability to eat sugars without symptoms

Category XIII

Increased sex drive

Tolerance to sugars reduced

“Splitting” type headaches

Category XIV (Males only)

Urination difficulty or dribbling

Frequent urination

Pain inside of legs or heels

Feeling of incomplete bowel evacuation

Leg nervousness at night

Category XV (Males only)

Decrease in libido

Decrease in spontaneous morning erections

Decrease in fullness of erections

Difficulty in maintaining morning erections

Spells of mental fatigue

Inability to concentrate

Episodes of depression

Muscle soreness

Decrease in physical stamina

Unexplained weight gain

Increase in fat distribution around chest and hips

Sweating attacks

More emotional than in the past

Category XVI (Menstruating Females Only)

Are you perimenopausal Yes No

Alternating menstrual cycle lengths Yes No

Extended menstrual cycle, greater than 32 days Yes No

Shortened menses, less than every 24 days Yes No

Pain and cramping during periods

Scanty blood flow

Heavy blood flow

Breast pain and swelling during menses

Pelvic pain during menses

Irritable and depressed during menses

Acne breakouts

Facial hair growth

Hair loss/thinning

Category XVII (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding? Yes No

Hot flashes

Mental fogginess

Disinterest in sex

Mood swings

Depression

Painful intercourse

Shrinking breasts

Facial hair growth

Acne

Increased vaginal pain, dryness or itching

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times a week do you eat raw nuts or seeds?

How many times a week do you eat fish?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Do you smoke? Yes No

If yes, how many times a day:

Rate your stress levels on a scale of 1-10 during the average week:

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

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

Please do not submit any Protected Health Information (PHI).

Location

Click the map to view the location nearest to you

Office Hours

Our regular schedule

ProNeuro Medical Group

Monday:

09:00 am - 06:00 pm

Tuesday:

09:00 am - 06:00 pm

Wednesday:

09:00 am - 06:00 pm

Thursday:

09:00 am - 06:00 pm

Friday:

09:00 am - 04:00 pm

Saturday:

09:00 am - 01:00 pm

Sunday:

Closed

NEWSLETTER SIGNUP

Sign up for more articles

Name

Phone

Please do not submit any Protected Health Information (PHI).

Button Text

Admin Log In
Site Map
Privacy Policy
Terms Of Use