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Metabolic Assessment Form & Neurotransmitter Assessment Form™ English

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3. Sex: *This question is required.
This question requires a valid date format of MM/DD/YYYY.
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Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
Metabolic Assessment Form 
Category I
7. Category I (Metabolic Assessment Form)
Feeling that bowels do not empty completely
8. Lower abdominal pain relieved by passing stool or gas
9. Alternating constipation and diarrhea
10. Diarrhea
11. Constipation
12. Hard, dry, or small stool
13. Hard, dry, or small stool
14. Coated tongue or “fuzzy” debris on tongue
15. Pass large amount of foul-smelling gas
16. More than 3 bowel movements daily
17. Use laxatives frequently
Category II
18. Category II
Increasing frequency of food reactions
19. Unpredictable food reactions
20. Aches, pains, and swelling throughout the body
21. Unpredictable abdominal swelling
22. Frequent bloating and distention after eating
Category III
23. Category III
Intolerance to smells
24. Intolerance to shampoo, lotion, detergents...
25. Constant skin outbreaks
Category IV
26. Category IV
Excessive belching, burping, or bloating
27. Gas immediately following a meal
28. Offensive breath
29. Difficult bowel movements
30. Sense of fullness during and after meals
31. Difficulty digesting proteins and meats; undigested food found in stools
Category V
32. Category V
Stomach pain, burning, or aching 1-4 hours after eating
33. Feel hungry an hour or two after eating
34. Heartburn when lying down or bending forward
35. Temporary relief by using antacids, food, milk, or carbonated beverages
36. Digestive problems subside with rest and relaxation
37. Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
Category VI
38. Category VI
Difficulty digesting roughage and fiber
39. Indigestion and fullness last 2-4 hours after eating
40. Pain, tenderness, soreness on left side under rib cage
41. Excessive passage of gas
42. Nausea and/or vomiting
43. Stool undigested, foul smelling, mucus like, greasy, or poorly formed
44. Frequent loss of appetite
Category VII
45. Category VII
Abdominal distention after consumption of fiber, starches, and sugar
46. Abdominal distention after certain probiotic or natural supplements
47. Decreased gastrointestinal motility, constipation
48. Increased gastrointestinal motility, diarrhea
49. Alternating constipation and diarrhea
50. Suspicion of nutritional malabsorption
51. Frequent use of antacid medication
52. Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?
Category VIII
53. Category VIII
Greasy or high-fat foods cause distress
54. Lower bowel gas and/or bloating several hours after eating
55. Bitter metallic taste in mouth, especially in the morning
56. Burpy, fishy taste after consuming fish oils
57. Unexplained itchy skin
58. Yellowish cast to eyes
59. Stool color alternates from clay colored to normal brown
60. Reddened skin, especially palms
61. Dry or flaky skin and/or hair
62. History of gallbladder attacks or stones
63. Have you had your gallbladder removed?
Category IX
64. Category IX
Acne and unhealthy skin
65. Excessive hair loss
66. Overall sense of bloating
67. Bodily swelling for no reason
68. Hormone imbalances
69. Weight gain
70. Poor bowel function
71. Excessively foul-smelling sweat
Category X
72. Category X
Crave sweets during the day
73. Irritable if meals are missed
74. Depend on coffee to keep going/get started
75. Get light-headed if meals are missed
76. Eating relieves fatigue
77. Feel shaky, jittery, or have tremors
78. Agitated, easily upset, nervous
79. Poor memory, forgetful between meals
80. Blurred vision
Category XI
81. Category XI
Fatigue after meals
82. Crave sweets during the day
83. Eating sweets does not relieve cravings for sugar
84. Must have sweets after meals
85. Waist girth is equal or larger than hip girth
86. Frequent urination
87. Increased thirst and appetite
88. Difficulty losing weight
Category XII
89. Category XII
Cannot stay asleep
90. Crave salt
91. Slow starter in the morning
92. Afternoon fatigue
93. Dizziness when standing up quickly
94. Afternoon headaches
95. Headaches with exertion or stress
96. Weak nails
Category XIII
97. Category XIII
Cannot fall asleep
98. Perspire easily
99. Under a high amount of stress
100. Weight gain when under stress
101. Wake up tired even after 6 or more hours of sleep
102. Excessive perspiration or perspiration with little or no activity
Category XIV
103. Category XIV
Edema and swelling in ankles and wrists
104. Muscle cramping
105. Poor muscle endurance
106. Frequent urination
107. Frequent thirst
108. Crave salt
109. Abnormal sweating from minimal activity
110. Alteration in bowel regularity
111. Inability to hold breath for long periods
112. Shallow, rapid breathing
Category XV
113. Category XV
114. Feel cold―hands, feet, all over
115. Require excessive amounts of sleep to function properly
116. Increase in weight even with low-calorie diet
117. Gain weight easily
118. Difficult, infrequent bowel movements
119. Depression/lack of motivation
120. Morning headaches that wear off as the day progresses
121. Outer third of eyebrow thins
122. Thinning of hair on scalp, face, or genitals, or excessive hair loss
123. Dryness of skin and/or scalp
124. Mental sluggishness
Category XVI
125. Category XVI
Heart palpitations
126. Inward trembling
127. Increased pulse even at rest
128. Nervous and emotional
129. Insomnia
130. Night sweats
131. Difficulty gaining weight
Category XVII (Males Only)
132. Category XVII (Males Only)
Urination difficulty or dribbling
133. Frequent urination
134. Pain inside of legs or heels
135. Feeling of incomplete bowel emptying
136. Leg twitching at night
Category XVIII (Males Only)
137. Category XVIII (Males Only)
Decreased libido
138. Decreased number of spontaneous morning erections
139. Decreased fullness of erections
140. Difficulty maintaining morning erections
141. Spells of mental fatigue
142. Inability to concentrate
143. Episodes of depression
144. Muscle soreness
145. Decreased physical stamina
146. Unexplained weight gain
147. Increase in fat distribution around chest and hips
148. Sweating attacks
149. More emotional than in the past
Category XIX (Menstruating Females Only)
150. Category XIX (Menstruating Females Only)
151. Alternating menstrual cycle lengths
152. Extended menstrual cycle (greater than 32 days)
153. Shortened menstrual cycle (less than 24 days)
154. Pain and cramping during periods
155. Scanty blood flow
156. Heavy blood flow
157. Breast pain and swelling during menses
158. Pelvic pain during menses
159. Irritable and depressed during menses
160. Acne
161. Facial hair growth
162. Hair loss/thinning
Category XX (Menopausal Females Only)
164. Since menopause, do you ever have uterine bleeding?
165. Hot flashes
166. Mental fogginess
167. Disinterest in sex
168. Mood swings
169. Depression
170. Painful intercourse
171. Shrinking breasts
172. Facial hair growth
173. Acne
174. Increased vaginal pain, dryness, or itching
Neurotransmitter Assessment Form™
186. Neurotransmitter Assessment Form™
Is your memory noticeably declining?
187.  Are you having a hard time remembering names and phone numbers?
188. Is your ability to focus noticeably declining?
189. Has it become harder for you to learn new things?
190. How often do you have a hard time remembering your appointments?
191. Is your temperament generally getting worse?
192. Is your attention span decreasing?
193. How often do you find yourself down or sad?
194. How often do you become fatigued when driving compared to in the past?
195. How often do you become fatigued when reading compared to in the past?
196. How often do you walk into rooms and forget why?
197. How often do you pick up your cell phone and forget why?
How high is your stress level?
199. How often do you feel you have something that must be done?
200. Do you feel you never have time for yourself?
201. How often do you feel you are not getting enough sleep or rest?
202. Do you find it difficult to get regular exercise?
203. Do you feel uncared for by the people in your life?
204. Do you feel you are not accomplishing your life’s purpose?
205. Is sharing your problems with someone difficult for you?
How often do you get irritable, shaky, or have light-headedness between meals?
207. How often do you feel energized after eating?
208. How often do you have difficulty eating large meals in the morning?
209. How often does your energy level drop in the afternoon?
210. How often do you crave sugar and sweets in the afternoon?
211. How often do you wake up in the middle of the night?
212. How often do you have difficulty concentrating before eating?
213. How often do you depend on coffee to keep yourself going?
214. How often do you feel agitated, easily upset, and nervous between meals?
How often do you get fatigued after meals?
216. How often do you crave sugar and sweets after meals?
217. How often do you feel you need stimulants, such as coffee, after meals?
218. How often do you have difficulty losing weight?
219. How much larger is your waist girth compared to your hip girth?
220. How often do you urinate?
221. Have your thirst and appetite increased?
222. How often do you gain weight when under stress?
223. How often do you have difficulty falling asleep?
224. SECTION 1
Are you losing interest in hobbies?
225. How often do you feel overwhelmed?
226. How often do you have feelings of inner rage?
227. How often do you have feelings of paranoia?
228. How often do you feel sad or down for no reason?
229. How often do you feel like you are not enjoying life?
230. How often do you feel you lack artistic appreciation?
231. How often do you feel depressed in overcast weather?
232. How much are you losing your enthusiasm for your favorite activities?
233. How much are you losing your enjoyment for your favorite foods?
234. How much are you losing your enjoyment of friendships and relationships?
235. How often do you have difficulty falling into deep, restful sleep?
236. How often do you have feelings of dependency on others?
237. How often do you feel more susceptible to pain?
238. How often do you have feelings of unprovoked anger?
239. How much are you losing interest in life?
240. SECTION 2
How often do you have feelings of hopelessness?
241. How often do you have self-destructive thoughts?
242. How often do you have an inability to handle stress?
243. How often do you have anger and aggression while under stress?
244. How often do you feel you are not rested, even after long hours of sleep?
245. How often do you prefer to isolate yourself from others?
246. How often do you have unexplained lack of concern for family and friends?
247. How easily are you distracted from your tasks?
248. How often do you have an inability to finish tasks?
249. How often do you feel the need to consume caffeine to stay alert?
250. How often do you feel your libido has been decreased?
251. How often do you lose your temper for minor reasons?
252. How often do you have feelings of worthlessness?
253. SECTION 3
How often do you feel anxious or panicked for no reason?
254. How often do you have feelings of dread or impending doom?
255. How often do you feel knots in your stomach?
256. How often do you have feelings of being overwhelmed for no reason?
257. How often do you have feelings of guilt about everyday decisions?
258. How often does your mind feel restless?
259. How difficult is it to turn your mind off when you want to relax?
260. How often do you have disorganized attention?
261. How often do you worry about things you were not worried about before?
262. How often do you have feelings of inner tension and inner excitability?
263. SECTION 4
Do you feel your visual memory (shapes & images) has decreased?
264. Do you feel your verbal memory has decreased?
265. Do you have memory lapses?
266. Has your creativity decreased?
267. Has your comprehension diminished?
268. Do you have difficulty calculating numbers?
269. Do you have difficulty recognizing objects & faces?
270. Do you feel like your opinion about yourself has changed?
271. Are you experiencing excessive urination?
272. Are you experiencing a slower mental response?
273. SECTION 5
A decrease in mental alertness
274. A decrease in mental speed
275. A decrease in concentration quality
276. Slow cognitive processing
277. Impaired mental performance
278. Need coffee or caffeine sources to improve mental function
279. SECTION 6
How would you grade your Brain fog (if any)?