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Home Metabolic Questionnaire

Metabolic Questionnaire

Name

Phone

Part 1: Symptoms

Rate each of the following symptoms based on how you’ve been feeling for the: Past 48 hours Past week Past 30 days

Point Scale

0 — Never or almost never have the symptoms
1 — Occasionally have it; effect is not severe
2 — Occasionally have it; effect is severe
3 — Frequently have it; effect is not severe
4 — Frequently have it; effect is severe

Head

Headaches

Faintness

Dizziness

Insomnia

Total

Eyes

Watery or itchy eyes

Swollen, reddened or sticky eyelids

Bags or dark circles under eyes

Blurred or tunnel vision (does not include near- or farsightedness)

Total

Ears

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

Total

Nose

Stuffy nose

Sinus problems

Hay fever

Sneezing attacks

Excessive mucus formation

Total

Mouth/Throat

Chronic coughing

Gagging, frequent need to clear throat

Sore throat, hoarseness, loss of voice

Swollen or discolored tongue, gums, or lips

Canker sores

Total

Skin

Acne

Hives, rashes, dry skin

Hair loss

Flushing, hot flashes

Excessive sweating

Total

Heart

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

Total

Lungs

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

Total

Digestive Tract

Nausea, vomiting

Diarrhea

Constipation

Bloated feeling

Belching, passing gas

Heartburn

Intestinal/stomach pain

Total

Joints/Muscles

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Pain or aches in muscles

Feeling of weakness or tiredness

Total

Weight

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention

Underweight

Total

Energy/Activity

Fatigue, sluggishness

Apathy, lethargy

Hyperactivity

Restlessness

Total

Mind

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

Total

Emotions

Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness

Depression

Total

Other

Frequent illness

Frequent or urgent urination

Genital itch or discharge

Total

Part 2: Xenobiotic Tolerability Test (XTT)

1. Are you presently using prescription drugs? Yes (1 pt.) No (0 pt.)

If yes, how many are you currently taking? (1 pt. each)

2. Are you presently taking one or more of the following over-the-counter drugs? Cimetidine (2 pts.) Acetaminophen (2 pts.) Estradiol (2 pts.)

3. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them: Experience side effects; drug(s) is (are) efficacious at lowered dose(s) (3 pts.) Experience side effects; drug(s) is (are) efficacious at usual dose(s) (2 pts.) Experience no side effects; drug(s) is (are) usually not efficacious (2 pts.) Experience no side effects; drug(s) is (are) usually efficacious (0 pt.)

4. Do you currently within the last 6 months have you regularly used tobacco products? Yes (2 pts.) No (0 pt.)

5. Do you have strong negative reactions to caffeine or caffeine-containing products? Yes (1 pt.) No (0 pt.) Don’t know (0 pt.)

6. Do you commonly experience “brain fog,” fatigue, or drowsiness? Yes (1 pt.) No (0 pt.)

7. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors? Yes (1 pt.) No (0 pt.) Don’t know (0 pt.)

8. Do you feel ill after you consume even small amounts of alcohol? Yes (1 pt.) No (0 pt.) Don’t know (0 pt.)

10. Do you have a personal history of: Environmental and/or chemical sensitivities (5 pts.) Chronic fatigue syndrome (5 pts.) Multiple chemical sensitivity (5 pts.) Fibromyalgia (3 pts.) Parkinson’s type symptoms (3 pts.) Alcohol or chemical dependence (2 pts.) Asthma (1 pt.)

11. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents? Yes (1 pt.) No (0 pt.)

12. Do you have an adverse or allergic reaction when you consume sulfite-containing foods such as wine, dried fruit, salad bar vegetables, etc.? Yes (1 pt.) No (0 pt.) Don’t know (0 pt.)

Total

Part 3: Alkalizing Assessment

1. Do you have a history of or currently have kidney dysfunction? Yes (1 pt.) No (0 pt.)

2. Have you ever been diagnosed with hyperkalemia? Yes (1 pt.) No (0 pt.)

3. Are you currently taking diuretics or blood pressure medication? Yes (1 pt.) No (0 pt.)

Total

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

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ProNeuro Medical Group

Monday:

09:00 am - 06:00 pm

Tuesday:

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Wednesday:

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Thursday:

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Friday:

09:00 am - 04:00 pm

Saturday:

09:00 am - 01:00 pm

Sunday:

Closed

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

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