Metabolic Assessment Form

Assess Your Metabolic Health

Metabolic Assessment Form

Date

Full Name

First

Last

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Sex

Phone

PART I

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

PART II

Please select the appropriate number on all questions below. 0 is the least/never to 3 as the most/always.

Category I

	0	1	2	3
Feeling that bowels do not empty completely	0Feeling that bowels do not empty completely 0	1Feeling that bowels do not empty completely 1	2Feeling that bowels do not empty completely 2	3Feeling that bowels do not empty completely 3
Lower abdominal pain relieved by passing stool or gas	0Lower abdominal pain relieved by passing stool or gas 0	1Lower abdominal pain relieved by passing stool or gas 1	2Lower abdominal pain relieved by passing stool or gas 2	3Lower abdominal pain relieved by passing stool or gas 3
Alternating constipation and diarrhea	0Alternating constipation and diarrhea 0	1Alternating constipation and diarrhea 1	2Alternating constipation and diarrhea 2	3Alternating constipation and diarrhea 3
Diarrhea	0Diarrhea 0	1Diarrhea 1	2Diarrhea 2	3Diarrhea 3
Constipation	0Constipation 0	1Constipation 1	2Constipation 2	3Constipation 3
Hard, dry, or small stool	0Hard, dry, or small stool 0	1Hard, dry, or small stool 1	2Hard, dry, or small stool 2	3Hard, dry, or small stool 3
Coated tongue or "fuzzy" debris on tongue	0Coated tongue or "fuzzy" debris on tongue 0	1Coated tongue or "fuzzy" debris on tongue 1	2Coated tongue or "fuzzy" debris on tongue 2	3Coated tongue or "fuzzy" debris on tongue 3
Pass large amount of foul-smelling gas	0Pass large amount of foul-smelling gas 0	1Pass large amount of foul-smelling gas 1	2Pass large amount of foul-smelling gas 2	3Pass large amount of foul-smelling gas 3
More than 3 bowel movements daily	0More than 3 bowel movements daily 0	1More than 3 bowel movements daily 1	2More than 3 bowel movements daily 2	3More than 3 bowel movements daily 3
Use laxatives frequently	0Use laxatives frequently 0	1Use laxatives frequently 1	2Use laxatives frequently 2	3Use laxatives frequently 3

Category II

	0	1	2	3
Increasing frequency of urination	0Increasing frequency of urination 0	1Increasing frequency of urination 1	2Increasing frequency of urination 2	3Increasing frequency of urination 3
Unpredictable food reactions	0Unpredictable food reactions 0	1Unpredictable food reactions 1	2Unpredictable food reactions 2	3Unpredictable food reactions 3
Aches, pains, and swelling throughout the body	0Aches, pains, and swelling throughout the body 0	1Aches, pains, and swelling throughout the body 1	2Aches, pains, and swelling throughout the body 2	3Aches, pains, and swelling throughout the body 3
Unpredictable abdominal pain	0Unpredictable abdominal pain 0	1Unpredictable abdominal pain 1	2Unpredictable abdominal pain 2	3Unpredictable abdominal pain 3
Frequent bloating and distension after eating	0Frequent bloating and distension after eating 0	1Frequent bloating and distension after eating 1	2Frequent bloating and distension after eating 2	3Frequent bloating and distension after eating 3
Abdominal cramps and to bloating and distention	0Abdominal cramps and to bloating and distention 0	1Abdominal cramps and to bloating and distention 1	2Abdominal cramps and to bloating and distention 2	3Abdominal cramps and to bloating and distention 3

Category III

	0	1	2	3
Intolerance to smells	0Intolerance to smells 0	1Intolerance to smells 1	2Intolerance to smells 2	3Intolerance to smells 3
Intolerance to jewelry	0Intolerance to jewelry 0	1Intolerance to jewelry 1	2Intolerance to jewelry 2	3Intolerance to jewelry 3
Intolerance to shampoo, lotions, detergents, etc.	0Intolerance to shampoo, lotions, detergents, etc. 0	1Intolerance to shampoo, lotions, detergents, etc. 1	2Intolerance to shampoo, lotions, detergents, etc. 2	3Intolerance to shampoo, lotions, detergents, etc. 3
Multiple small and chemical sensitivities	0Multiple small and chemical sensitivities 0	1Multiple small and chemical sensitivities 1	2Multiple small and chemical sensitivities 2	3Multiple small and chemical sensitivities 3
Constant skin outbreaks	0Constant skin outbreaks 0	1Constant skin outbreaks 1	2Constant skin outbreaks 2	3Constant skin outbreaks 3

Category IV

	0	1	2	3
Excessive belching, burping, or bloating	0Excessive belching, burping, or bloating 0	1Excessive belching, burping, or bloating 1	2Excessive belching, burping, or bloating 2	3Excessive belching, burping, or bloating 3
Gas immediately following a meal	0Gas immediately following a meal 0	1Gas immediately following a meal 1	2Gas immediately following a meal 2	3Gas immediately following a meal 3
Offensive breath	0Offensive breath 0	1Offensive breath 1	2Offensive breath 2	3Offensive breath 3
Difficult bowel movement	0Difficult bowel movement 0	1Difficult bowel movement 1	2Difficult bowel movement 2	3Difficult bowel movement 3
Sense of fullness during and after meals	0Sense of fullness during and after meals 0	1Sense of fullness during and after meals 1	2Sense of fullness during and after meals 2	3Sense of fullness during and after meals 3
Difficulty digesting fruits and vegetables; undigested food noted in stool	0Difficulty digesting fruits and vegetables; undigested food noted in stool 0	1Difficulty digesting fruits and vegetables; undigested food noted in stool 1	2Difficulty digesting fruits and vegetables; undigested food noted in stool 2	3Difficulty digesting fruits and vegetables; undigested food noted in stool 3

Category V

	0	1	2	3
Stomach pain, burning, or aching 1-4 hours after eating	0Stomach pain, burning, or aching 1-4 hours after eating 0	1Stomach pain, burning, or aching 1-4 hours after eating 1	2Stomach pain, burning, or aching 1-4 hours after eating 2	3Stomach pain, burning, or aching 1-4 hours after eating 3
Use antacids	0Use antacids 0	1Use antacids 1	2Use antacids 2	3Use antacids 3
Feel hungry an hour or two after eating	0Feel hungry an hour or two after eating 0	1Feel hungry an hour or two after eating 1	2Feel hungry an hour or two after eating 2	3Feel hungry an hour or two after eating 3
Heartburn when lying down or bending forward	0Heartburn when lying down or bending forward 0	1Heartburn when lying down or bending forward 1	2Heartburn when lying down or bending forward 2	3Heartburn when lying down or bending forward 3
Temporary relief by using antacids, food, milk, or carbonated beverages	0Temporary relief by using antacids, food, milk, or carbonated beverages 0	1Temporary relief by using antacids, food, milk, or carbonated beverages 1	2Temporary relief by using antacids, food, milk, or carbonated beverages 2	3Temporary relief by using antacids, food, milk, or carbonated beverages 3
Digestive problems subside with rest	0Digestive problems subside with rest 0	1Digestive problems subside with rest 1	2Digestive problems subside with rest 2	3Digestive problems subside with rest 3
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine	0Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine 0	1Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine 1	2Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine 2	3Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine 3

Category VI

	0	1	2	3
Roughage and fiber cause constipation	0Roughage and fiber cause constipation 0	1Roughage and fiber cause constipation 1	2Roughage and fiber cause constipation 2	3Roughage and fiber cause constipation 3
Indigestion and fullness last 2-4 hours after eating	0Indigestion and fullness last 2-4 hours after eating 0	1Indigestion and fullness last 2-4 hours after eating 1	2Indigestion and fullness last 2-4 hours after eating 2	3Indigestion and fullness last 2-4 hours after eating 3
Pain, tenderness, soreness on left side under rib cage	0Pain, tenderness, soreness on left side under rib cage 0	1Pain, tenderness, soreness on left side under rib cage 1	2Pain, tenderness, soreness on left side under rib cage 2	3Pain, tenderness, soreness on left side under rib cage 3
Excessive passage of gas	0Excessive passage of gas 0	1Excessive passage of gas 1	2Excessive passage of gas 2	3Excessive passage of gas 3
Stool undigested, foul smelling, mucous-like, greasy, or poorly formed	0Stool undigested, foul smelling, mucous-like, greasy, or poorly formed 0	1Stool undigested, foul smelling, mucous-like, greasy, or poorly formed 1	2Stool undigested, foul smelling, mucous-like, greasy, or poorly formed 2	3Stool undigested, foul smelling, mucous-like, greasy, or poorly formed 3
Frequent urination	0Frequent urination 0	1Frequent urination 1	2Frequent urination 2	3Frequent urination 3
Increased thirst and appetite	0Increased thirst and appetite 0	1Increased thirst and appetite 1	2Increased thirst and appetite 2	3Increased thirst and appetite 3
Difficulty losing weight	0Difficulty losing weight 0	1Difficulty losing weight 1	2Difficulty losing weight 2	3Difficulty losing weight 3

Category VII

	0	1	2	3
Greasy or high-fat foods cause distress	0Greasy or high-fat foods cause distress 0	1Greasy or high-fat foods cause distress 1	2Greasy or high-fat foods cause distress 2	3Greasy or high-fat foods cause distress 3
Lower bowel gas and/or bloating several hours after eating	0Lower bowel gas and/or bloating several hours after eating 0	1Lower bowel gas and/or bloating several hours after eating 1	2Lower bowel gas and/or bloating several hours after eating 2	3Lower bowel gas and/or bloating several hours after eating 3
Bitter metallic taste in mouth, especially in the morning	0Bitter metallic taste in mouth, especially in the morning 0	1Bitter metallic taste in mouth, especially in the morning 1	2Bitter metallic taste in mouth, especially in the morning 2	3Bitter metallic taste in mouth, especially in the morning 3
Unexplained itchy skin	0Unexplained itchy skin 0	1Unexplained itchy skin 1	2Unexplained itchy skin 2	3Unexplained itchy skin 3
Yellowish cast to eyes	0Yellowish cast to eyes 0	1Yellowish cast to eyes 1	2Yellowish cast to eyes 2	3Yellowish cast to eyes 3
Stool color alternates from clay colored to normal brown	0Stool color alternates from clay colored to normal brown 0	1Stool color alternates from clay colored to normal brown 1	2Stool color alternates from clay colored to normal brown 2	3Stool color alternates from clay colored to normal brown 3
Reddened skin, especially palms	0Reddened skin, especially palms 0	1Reddened skin, especially palms 1	2Reddened skin, especially palms 2	3Reddened skin, especially palms 3
Dry or flaky skin and/or hair	0Dry or flaky skin and/or hair 0	1Dry or flaky skin and/or hair 1	2Dry or flaky skin and/or hair 2	3Dry or flaky skin and/or hair 3
History of gallbladder attacks or stones	0History of gallbladder attacks or stones 0	1History of gallbladder attacks or stones 1	2History of gallbladder attacks or stones 2	3History of gallbladder attacks or stones 3

Have you had your gallbladder removed?

Category IX

	0	1	2	3
Crave sweets during the day	0Crave sweets during the day 0	1Crave sweets during the day 1	2Crave sweets during the day 2	3Crave sweets during the day 3
Irritable if meals are missed	0Irritable if meals are missed 0	1Irritable if meals are missed 1	2Irritable if meals are missed 2	3Irritable if meals are missed 3
Depend on coffee to keep going/get started	0Depend on coffee to keep going/get started 0	1Depend on coffee to keep going/get started 1	2Depend on coffee to keep going/get started 2	3Depend on coffee to keep going/get started 3
Get light-headed if meals are missed	0Get light-headed if meals are missed 0	1Get light-headed if meals are missed 1	2Get light-headed if meals are missed 2	3Get light-headed if meals are missed 3
Eating relieves fatigue	0Eating relieves fatigue 0	1Eating relieves fatigue 1	2Eating relieves fatigue 2	3Eating relieves fatigue 3
Feel shaky, jittery, or have tremors	0Feel shaky, jittery, or have tremors 0	1Feel shaky, jittery, or have tremors 1	2Feel shaky, jittery, or have tremors 2	3Feel shaky, jittery, or have tremors 3
Agitated, easily upset, nervous	0Agitated, easily upset, nervous 0	1Agitated, easily upset, nervous 1	2Agitated, easily upset, nervous 2	3Agitated, easily upset, nervous 3
Poor memory/forgetful	0Poor memory/forgetful 0	1Poor memory/forgetful 1	2Poor memory/forgetful 2	3Poor memory/forgetful 3
Blurred vision	0Blurred vision 0	1Blurred vision 1	2Blurred vision 2	3Blurred vision 3

Category X

	0	1	2	3
Fatigue after meals	0Fatigue after meals 0	1Fatigue after meals 1	2Fatigue after meals 2	3Fatigue after meals 3
Crave sweets during the day	0Crave sweets during the day 0	1Crave sweets during the day 1	2Crave sweets during the day 2	3Crave sweets during the day 3
Eating sweets does not relieve cravings for sugar	0Eating sweets does not relieve cravings for sugar 0	1Eating sweets does not relieve cravings for sugar 1	2Eating sweets does not relieve cravings for sugar 2	3Eating sweets does not relieve cravings for sugar 3
Must have sweets after meals	0Must have sweets after meals 0	1Must have sweets after meals 1	2Must have sweets after meals 2	3Must have sweets after meals 3
Waist girth is equal or larger than hip girth	0Waist girth is equal or larger than hip girth 0	1Waist girth is equal or larger than hip girth 1	2Waist girth is equal or larger than hip girth 2	3Waist girth is equal or larger than hip girth 3
Frequent urination	0Frequent urination 0	1Frequent urination 1	2Frequent urination 2	3Frequent urination 3
Increased thirst and appetite	0Increased thirst and appetite 0	1Increased thirst and appetite 1	2Increased thirst and appetite 2	3Increased thirst and appetite 3
Difficulty losing weight	0Difficulty losing weight 0	1Difficulty losing weight 1	2Difficulty losing weight 2	3Difficulty losing weight 3

Category XI

	0	1	2	3
Cannot stay asleep	0Cannot stay asleep 0	1Cannot stay asleep 1	2Cannot stay asleep 2	3Cannot stay asleep 3
Crave salt	0Crave salt 0	1Crave salt 1	2Crave salt 2	3Crave salt 3
Slow starter in the morning	0Slow starter in the morning 0	1Slow starter in the morning 1	2Slow starter in the morning 2	3Slow starter in the morning 3
Afternoon fatigue	0Afternoon fatigue 0	1Afternoon fatigue 1	2Afternoon fatigue 2	3Afternoon fatigue 3
Dizziness when standing up quickly	0Dizziness when standing up quickly 0	1Dizziness when standing up quickly 1	2Dizziness when standing up quickly 2	3Dizziness when standing up quickly 3
Afternoon headaches	0Afternoon headaches 0	1Afternoon headaches 1	2Afternoon headaches 2	3Afternoon headaches 3
Headaches with exertion or stress	0Headaches with exertion or stress 0	1Headaches with exertion or stress 1	2Headaches with exertion or stress 2	3Headaches with exertion or stress 3
Weak nails	0Weak nails 0	1Weak nails 1	2Weak nails 2	3Weak nails 3

Category XII

	0	1	2	3
Edema and swelling in ankles and wrists	0Edema and swelling in ankles and wrists 0	1Edema and swelling in ankles and wrists 1	2Edema and swelling in ankles and wrists 2	3Edema and swelling in ankles and wrists 3
Muscle cramping	0Muscle cramping 0	1Muscle cramping 1	2Muscle cramping 2	3Muscle cramping 3
Poor muscle endurance	0Poor muscle endurance 0	1Poor muscle endurance 1	2Poor muscle endurance 2	3Poor muscle endurance 3
Frequent urination	0Frequent urination 0	1Frequent urination 1	2Frequent urination 2	3Frequent urination 3
Frequent thirst	0Frequent thirst 0	1Frequent thirst 1	2Frequent thirst 2	3Frequent thirst 3
Crave salt	0Crave salt 0	1Crave salt 1	2Crave salt 2	3Crave salt 3
Abnormal sweating from internal activity	0Abnormal sweating from internal activity 0	1Abnormal sweating from internal activity 1	2Abnormal sweating from internal activity 2	3Abnormal sweating from internal activity 3

Category XIII

	0	1	2	3
Alteration in bowel regularity	0Alteration in bowel regularity 0	1Alteration in bowel regularity 1	2Alteration in bowel regularity 2	3Alteration in bowel regularity 3
Inability to hold breath for long periods	0Inability to hold breath for long periods 0	1Inability to hold breath for long periods 1	2Inability to hold breath for long periods 2	3Inability to hold breath for long periods 3
Shallow, rapid breathing	0Shallow, rapid breathing 0	1Shallow, rapid breathing 1	2Shallow, rapid breathing 2	3Shallow, rapid breathing 3

Category XIV

	0	1	2	3
Tired/sluggish	0Tired/sluggish 0	1Tired/sluggish 1	2Tired/sluggish 2	3Tired/sluggish 3
Feel cold—hands, feet, all over	0Feel cold—hands, feet, all over 0	1Feel cold—hands, feet, all over 1	2Feel cold—hands, feet, all over 2	3Feel cold—hands, feet, all over 3
Require excessive amounts of sleep to function properly	0Require excessive amounts of sleep to function properly 0	1Require excessive amounts of sleep to function properly 1	2Require excessive amounts of sleep to function properly 2	3Require excessive amounts of sleep to function properly 3
Increase in weight even with low-calorie diet	0Increase in weight even with low-calorie diet 0	1Increase in weight even with low-calorie diet 1	2Increase in weight even with low-calorie diet 2	3Increase in weight even with low-calorie diet 3
Gain weight easily	0Gain weight easily 0	1Gain weight easily 1	2Gain weight easily 2	3Gain weight easily 3
Difficult, infrequent bowel movements	0Difficult, infrequent bowel movements 0	1Difficult, infrequent bowel movements 1	2Difficult, infrequent bowel movements 2	3Difficult, infrequent bowel movements 3
Depression/lack of motivation	0Depression/lack of motivation 0	1Depression/lack of motivation 1	2Depression/lack of motivation 2	3Depression/lack of motivation 3
Morning headaches that wear off as the day progresses	0Morning headaches that wear off as the day progresses 0	1Morning headaches that wear off as the day progresses 1	2Morning headaches that wear off as the day progresses 2	3Morning headaches that wear off as the day progresses 3
Outer third of eyebrow thins	0Outer third of eyebrow thins 0	1Outer third of eyebrow thins 1	2Outer third of eyebrow thins 2	3Outer third of eyebrow thins 3
Thinning of hair on scalp, face, or genitals	0Thinning of hair on scalp, face, or genitals 0	1Thinning of hair on scalp, face, or genitals 1	2Thinning of hair on scalp, face, or genitals 2	3Thinning of hair on scalp, face, or genitals 3
Dryness of skin and/or scalp	0Dryness of skin and/or scalp 0	1Dryness of skin and/or scalp 1	2Dryness of skin and/or scalp 2	3Dryness of skin and/or scalp 3
Mental sluggishness	0Mental sluggishness 0	1Mental sluggishness 1	2Mental sluggishness 2	3Mental sluggishness 3

Category XV

	0	1	2	3
Heart palpitations	0Heart palpitations 0	1Heart palpitations 1	2Heart palpitations 2	3Heart palpitations 3
Inward trembling	0Inward trembling 0	1Inward trembling 1	2Inward trembling 2	3Inward trembling 3
Increased pulse even at rest	0Increased pulse even at rest 0	1Increased pulse even at rest 1	2Increased pulse even at rest 2	3Increased pulse even at rest 3
Nervous and emotional	0Nervous and emotional 0	1Nervous and emotional 1	2Nervous and emotional 2	3Nervous and emotional 3
Insomnia	0Insomnia 0	1Insomnia 1	2Insomnia 2	3Insomnia 3
Night sweats	0Night sweats 0	1Night sweats 1	2Night sweats 2	3Night sweats 3
Difficulty gaining weight	0Difficulty gaining weight 0	1Difficulty gaining weight 1	2Difficulty gaining weight 2	3Difficulty gaining weight 3

Category XVI

	0	1	2	3
Diminished sex drive	0Diminished sex drive 0	1Diminished sex drive 1	2Diminished sex drive 2	3Diminished sex drive 3
Menstrual disorders or lack of menstruation	0Menstrual disorders or lack of menstruation 0	1Menstrual disorders or lack of menstruation 1	2Menstrual disorders or lack of menstruation 2	3Menstrual disorders or lack of menstruation 3
Increased ability to eat sugars without symptoms	0Increased ability to eat sugars without symptoms 0	1Increased ability to eat sugars without symptoms 1	2Increased ability to eat sugars without symptoms 2	3Increased ability to eat sugars without symptoms 3

Category XVII

	0	1	2	3
Increased sex drive	0Increased sex drive 0	1Increased sex drive 1	2Increased sex drive 2	3Increased sex drive 3
Tolerance to sugars reduced	0Tolerance to sugars reduced 0	1Tolerance to sugars reduced 1	2Tolerance to sugars reduced 2	3Tolerance to sugars reduced 3

Category XVIII (Males Only)

	0	1	2	3
Urinating difficulty or dribbling	0Urinating difficulty or dribbling 0	1Urinating difficulty or dribbling 1	2Urinating difficulty or dribbling 2	3Urinating difficulty or dribbling 3
Frequent urination	0Frequent urination 0	1Frequent urination 1	2Frequent urination 2	3Frequent urination 3
Pain inside of legs or heels	0Pain inside of legs or heels 0	1Pain inside of legs or heels 1	2Pain inside of legs or heels 2	3Pain inside of legs or heels 3
Feeling of incomplete bowel emptying	0Feeling of incomplete bowel emptying 0	1Feeling of incomplete bowel emptying 1	2Feeling of incomplete bowel emptying 2	3Feeling of incomplete bowel emptying 3
Leg twitching at night	0Leg twitching at night 0	1Leg twitching at night 1	2Leg twitching at night 2	3Leg twitching at night 3

Category XIX (Males Only)

	0	1	2	3
Decreased libido	0Decreased libido 0	1Decreased libido 1	2Decreased libido 2	3Decreased libido 3
Decreased number of morning and nighttime erections	0Decreased number of morning and nighttime erections 0	1Decreased number of morning and nighttime erections 1	2Decreased number of morning and nighttime erections 2	3Decreased number of morning and nighttime erections 3
Decreased fullness of erection	0Decreased fullness of erection 0	1Decreased fullness of erection 1	2Decreased fullness of erection 2	3Decreased fullness of erection 3
Difficulty maintaining morning erections	0Difficulty maintaining morning erections 0	1Difficulty maintaining morning erections 1	2Difficulty maintaining morning erections 2	3Difficulty maintaining morning erections 3
Spells of mental fatigue	0Spells of mental fatigue 0	1Spells of mental fatigue 1	2Spells of mental fatigue 2	3Spells of mental fatigue 3
Inability to concentrate	0Inability to concentrate 0	1Inability to concentrate 1	2Inability to concentrate 2	3Inability to concentrate 3
Episodes of depression	0Episodes of depression 0	1Episodes of depression 1	2Episodes of depression 2	3Episodes of depression 3
Muscle soreness	0Muscle soreness 0	1Muscle soreness 1	2Muscle soreness 2	3Muscle soreness 3
Decreased physical stamina	0Decreased physical stamina 0	1Decreased physical stamina 1	2Decreased physical stamina 2	3Decreased physical stamina 3
Unexplained weight gain	0Unexplained weight gain 0	1Unexplained weight gain 1	2Unexplained weight gain 2	3Unexplained weight gain 3
Increase in fat distribution around chest and hips	0Increase in fat distribution around chest and hips 0	1Increase in fat distribution around chest and hips 1	2Increase in fat distribution around chest and hips 2	3Increase in fat distribution around chest and hips 3
Sweating attacks	0Sweating attacks 0	1Sweating attacks 1	2Sweating attacks 2	3Sweating attacks 3
More emotional than in the past	0More emotional than in the past 0	1More emotional than in the past 1	2More emotional than in the past 2	3More emotional than in the past 3

Category XX (Menstruating Females Only)

Premenopause

Alternating menstrual cycle lengths

Extended menstrual cycle (greater than 32 days)

Shortened menstrual cycle (less than 24 days)

	0	1	2	3
Pain and cramping during periods	0Pain and cramping during periods 0	1Pain and cramping during periods 1	2Pain and cramping during periods 2	3Pain and cramping during periods 3
Scanty blood flow	0Scanty blood flow 0	1Scanty blood flow 1	2Scanty blood flow 2	3Scanty blood flow 3
Heavy blood flow	0Heavy blood flow 0	1Heavy blood flow 1	2Heavy blood flow 2	3Heavy blood flow 3
Breast pain and swelling during menses	0Breast pain and swelling during menses 0	1Breast pain and swelling during menses 1	2Breast pain and swelling during menses 2	3Breast pain and swelling during menses 3
Pelvic pain during menses	0Pelvic pain during menses 0	1Pelvic pain during menses 1	2Pelvic pain during menses 2	3Pelvic pain during menses 3
Irritable and depressed during menses	0Irritable and depressed during menses 0	1Irritable and depressed during menses 1	2Irritable and depressed during menses 2	3Irritable and depressed during menses 3
Acne	0Acne 0	1Acne 1	2Acne 2	3Acne 3
Facial hair growth	0Facial hair growth 0	1Facial hair growth 1	2Facial hair growth 2	3Facial hair growth 3
Hair loss/thinning	0Hair loss/thinning 0	1Hair loss/thinning 1	2Hair loss/thinning 2	3Hair loss/thinning 3

Category XXI (Menopaused Females Only)

How many years have you been menopaused?

Since menopause, do you ever have citrus bleeding?

	0	1	2	3
Hot flushes	0Hot flushes 0	1Hot flushes 1	2Hot flushes 2	3Hot flushes 3
Mental fogginess	0Mental fogginess 0	1Mental fogginess 1	2Mental fogginess 2	3Mental fogginess 3
Disinterest in sex	0Disinterest in sex 0	1Disinterest in sex 1	2Disinterest in sex 2	3Disinterest in sex 3
Mood swings	0Mood swings 0	1Mood swings 1	2Mood swings 2	3Mood swings 3
Depression	0Depression 0	1Depression 1	2Depression 2	3Depression 3
Painful intercourse	0Painful intercourse 0	1Painful intercourse 1	2Painful intercourse 2	3Painful intercourse 3
Shrinking breasts	0Shrinking breasts 0	1Shrinking breasts 1	2Shrinking breasts 2	3Shrinking breasts 3
Facial hair growth	0Facial hair growth 0	1Facial hair growth 1	2Facial hair growth 2	3Facial hair growth 3
Acne	0Acne 0	1Acne 1	2Acne 2	3Acne 3
Increased vaginal pain, dryness, or itching	0Increased vaginal pain, dryness, or itching 0	1Increased vaginal pain, dryness, or itching 1	2Increased vaginal pain, dryness, or itching 2	3Increased vaginal pain, dryness, or itching 3

PART III

How many alcoholic beverages do you consume per week?

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

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat out and eat per week?

How many times do you work out per week?

How many times do you take and/or smoke per week?

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

List the three healthiest foods you eat during the average 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