Microsoft word - smgemaf04_0708_-press.doc

Metabolic Assessment Form

Name: ____________________________________________________ Age: ______ Sex: _____ Date: ______________

PART I
Please list the 5 major health concerns in your order of importance:
1. _____________________________________________________________________________________________
2. _____________________________________________________________________________________________
3. _____________________________________________________________________________________________
4. _____________________________________________________________________________________________
5. _____________________________________________________________________________________________
PART II
Please circle the appropriate number “0 - 3” on all questions below.
0 as the least/never to 3 as the most/always.

Category I
Category V
Feeling that bowels do not empty completely Lower abdominal pain relief by passing stool or gas Coated tongue of “fuzzy” debris on tongue Stool color alternates from clay colored Category
History of gallbladder attacks or stones Excessive belching, burping, or bloating Category VI
Sense of fullness during and after meals Difficulty digesting fruits and vegetables; Depend on coffee to keep yourself going or started Category
Stomach pain, burning, or aching 1- 4 hours after eating Feeling hungry an hour or two after eating Heartburn when lying down or bending forward Category
Digestive problems subside with rest and relaxation Heartburn due to spicy foods, chocolate, citrus, Eating sweets does not relieve cravings for sugar Category IV
Waist girth is equal or larger than hip girth Pain, tenderness, soreness on left side Category VIII
Symptom groups listed in this flyer are not intended to be used as a diagnosis of any disease condition. All Rights Reserved. Copyright  2008, Datis Kharrazian SMGEMAF04(0708)-PRESS.DOC

Category IX
Category
Wake up tired even after 6 or more hours of sleep Excessive perspiration or perspiration with Category XV (Males Only)
Category X
Decrease in spontaneous morning erections Difficulty in maintain morning erections Increase in weight gain even with low-calorie diet 0 1 2 3
Increase in fat distribution around chest and hips Thinning of hair on scalp, face or genitals or Category XVI (Menstruating Females Only)
Extended menstrual cycle, greater than 32 days Category XI
Shortened menses, less than every 24 days Category XII
Category XVII (Menopausal Females Only)
Menstrual disorders or lack of menstruation How many years have you been menopausal? ________
Increased ability to eat sugars without symptoms Since menopause, do you ever have uterine bleeding? Category XIII
Increased vaginal pain, dryness or itching How many alcohol 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? ___________ How many times a week do you workout? ____________ 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?_______ 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:
_______________________________________________________________________________________________________________
All Rights Reserved. Copyright  2008, Datis Kharrazian SMGEMAF04(0708)-PRESS.DOC

Source: http://lifetimewellness.biz/pdfs/Metabolic_Assessment_Form.pdf