Metabolic Assessment Form

Please fill out this metabolic assessment form, the patient intake form, the wellness evaluation form, and the neurotransmitter assessment form. Be sure to submit them before your wellness consultation, so Dr. Dae can review them and create a wellness plan for you.

First Name *

Last Name *

Phone *

Age

Sex

Today's Date

PART I:

Please list your 5 major health concerns in order of importance.

Major Health Concern #1:

Major Health Concern #2:

Major Health Concern #3:

Major Health Concern #4:

Major Health Concern #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

Lower abdominal pain relieved by passing stool or gas

Alternating constipation and diarrhea

Diarrhea

Constipation

Feeling that bowels do not empty completely

Coated tongue or "fuzzy" debris on tongue

Pass large amount of foul-smelling gas

More than 3 bowel movements daily

Use laxatives frequently

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Hard, dry or small stool

Category II

Increasing frequency of food reactions

Unpredictable food reactions

Aches, pains and swelling throughout the body

Unpredictable abdominal swelling

Frequent bloating and distention after eating

Abdominal intolerance to sugars and starches

Category III

Intolerance to smells

Intolerance to jewelry

Intolerance to shampoo, lotion, detergents, etc.

Multiple smell and chemical sensitivities

Constant skin outbreaks

Category IV

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 food found in stools

Category V

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

Use of antacids

Feel hungry an hour or two after eating

Heartburn when lying down or bending forward

Temporary relief by using antacids, food, milk or carbonated beverages

Digestive problems subside with rest and relaxation

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

Category VI

Roughage and fiber cause constipation

Indigestion and fullness last 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

Category VII

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

Burpy, fishy taste after consuming fish oils

Difficulty losing weight

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?

Category VIII

Unhealthy skin or Acne

Excessive hair loss

Overall sense of bloating

Bodily swelling for no reason

Hormone imbalances

Weight gain

Poor bowel function

Excessively foul-smelling sweat

Category IX

Crave sweets during the day

Irritable if meals are missed

Depend on coffee to keep going/get started

Get light headed if meals are missed

Eating relieves fatigue

Feel shaky, jittery or have tremors

Agitated, easily upset, nervous

Poor memory/forgetful

Blurred vision

Category X

Fatigue after meals

Crave sweets, but eating them does not relieve symptoms. *

Must have sweets after meals

Waist girth is equal or larger than hip girth

Frequent urination

Difficulty losing weight

Category XI

Can not 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 XII:

Cannot fall asleep

Perspire easily

Under a high amount 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 XIII

Edema and swelling in ankles and wrists

Muscle cramping

Poor muscle endurance

Frequent thirst

Alteration in bowel regularity

Inability to hold breath for long periods

Shallow, rapid breathing

Category XIV

Tired/sluggish

Feel cold - hands, feet, all over

Require excessive amounts of sleep to function properly

Increase in weight even with low calorie diet

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 hair loss

Dryness of skin and/or scalp

Mental sluggishness

Category XV

Heart palpitations

Inward trembling

Increased pulse even at rest

Nervous and emotional

Insomnia

Night sweats

Difficulty gaining weight

Category XVI

Urination difficulty or dribbling

Pain inside of legs or heels

Feeling of incomplete bowel emptying

Leg twitching at night

Category XVII (Males Only)

Decreased libido

Decreased number of spontaneous morning erections

Decreased fullness of erection

Difficulty maintaining morning erections

Spells of mental fatigue

Inability to concentrate

Episodes of depression

Muscle soreness

Decreased physical stamina

Unexplained weight gain

Increase in fat distribution around chest and hips

Sweating attacks

More emotional than in the past

Category XVIII: Menstruating Females Only

Perimenopausal

Alternating menstrual cycle lengths

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Shortened menstrual cycle: Less than 24 days

Extended menstrual cycle: Greater than 32 days

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

Facial hair growth

Hair loss/thinning

Category XIX: Menopausal Females Only

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?

Hot Flashes

Mental fogginess

Disinterest in sex

Mood swings

Depression

Painful intercourse

Shrinking breasts

Facial hair growth

Acne

Increased vaginal pain, dryness or itching

PART III:

How many alcoholic beverages do you consumer per week?

How many caffeinated beverages do you consume per week?

How many times do you eat 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:

Rate your stress level on a scale of 1-10 during the average week.

How many times do you eat fish per week?

How many times do you work out per 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.