Metabolic Assessment Form & Neurotransmitter Assessment Form™ English

3. Sex: *This question is required.

• Male
• Female
• Non of the above

7. Category I (Metabolic Assessment Form)
Feeling that bowels do not empty completely

• 0
• 1
• 2
• 3

8. Lower abdominal pain relieved by passing stool or gas

• 0
• 1
• 2
• 3

9. Alternating constipation and diarrhea

• 0
• 1
• 2
• 3

10. Diarrhea
 

• 0
• 1
• 2
• 3

11. Constipation

• 0
• 1
• 2
• 3

12. Hard, dry, or small stool

• 0
• 1
• 2
• 3

13. Hard, dry, or small stool

• 0
• 1
• 2
• 3

14. Coated tongue or “fuzzy” debris on tongue

• 0
• 1
• 2
• 3

15. Pass large amount of foul-smelling gas

• 0
• 1
• 2
• 3

16. More than 3 bowel movements daily

• 0
• 1
• 2
• 3

17. Use laxatives frequently

• 0
• 1
• 2
• 3

18. Category II
Increasing frequency of food reactions

• 0
• 1
• 2
• 3

19. Unpredictable food reactions

• 0
• 1
• 2
• 3

20. Aches, pains, and swelling throughout the body

• 0
• 1
• 2
• 3

21. Unpredictable abdominal swelling

• 0
• 1
• 2
• 3

22. Frequent bloating and distention after eating

• 0
• 1
• 2
• 3

23. Category III
Intolerance to smells

• 0
• 1
• 2
• 3

24. Intolerance to shampoo, lotion, detergents...

• 0
• 1
• 2
• 3

25. Constant skin outbreaks

• 0
• 1
• 2
• 3

26. Category IV
Excessive belching, burping, or bloating

• 0
• 1
• 2
• 3

27. Gas immediately following a meal

• 0
• 1
• 2
• 3

28. Offensive breath

• 0
• 1
• 2
• 3

29. Difficult bowel movements

• 0
• 1
• 2
• 3

30. Sense of fullness during and after meals

• 0
• 1
• 2
• 3

31. Difficulty digesting proteins and meats; undigested food found in stools

• 0
• 1
• 2
• 3

32. Category V
Stomach pain, burning, or aching 1-4 hours after eating

• 0
• 1
• 2
• 3

33. Feel hungry an hour or two after eating

• 0
• 1
• 2
• 3

34. Heartburn when lying down or bending forward

• 0
• 1
• 2
• 3

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

• 0
• 1
• 2
• 3

36. Digestive problems subside with rest and relaxation

• 0
• 1
• 2
• 3

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

• 0
• 1
• 2
• 3

38. Category VI
Difficulty digesting roughage and fiber

• 0
• 1
• 2
• 3

39. Indigestion and fullness last 2-4 hours after eating

• 0
• 1
• 2
• 3

40. Pain, tenderness, soreness on left side under rib cage

• 0
• 1
• 2
• 3

41. Excessive passage of gas

• 0
• 1
• 2
• 3

42. Nausea and/or vomiting

• 0
• 1
• 2
• 3

43. Stool undigested, foul smelling, mucus like, greasy, or poorly formed

• 0
• 1
• 2
• 3

44. Frequent loss of appetite

• 0
• 1
• 2
• 3

45. Category VII
Abdominal distention after consumption of fiber, starches, and sugar

• 0
• 1
• 2
• 3

46. Abdominal distention after certain probiotic or natural supplements

• 0
• 1
• 2
• 3

47. Decreased gastrointestinal motility, constipation

• 0
• 1
• 2
• 3

48. Increased gastrointestinal motility, diarrhea

• 0
• 1
• 2
• 3

49. Alternating constipation and diarrhea

• 0
• 1
• 2
• 3

50. Suspicion of nutritional malabsorption

• 0
• 1
• 2
• 3

51. Frequent use of antacid medication

• 0
• 1
• 2
• 3

52. Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?

• yes
• no

53. Category VIII
Greasy or high-fat foods cause distress

• 0
• 1
• 2
• 3

54. Lower bowel gas and/or bloating several hours after eating

• 0
• 1
• 2
• 3

55. Bitter metallic taste in mouth, especially in the morning

• 0
• 1
• 2
• 3

56. Burpy, fishy taste after consuming fish oils

• 0
• 1
• 2
• 3

57. Unexplained itchy skin

• 0
• 1
• 2
• 3

58. Yellowish cast to eyes

• 0
• 1
• 2
• 3

59. Stool color alternates from clay colored to normal brown

• 0
• 1
• 2
• 3

60. Reddened skin, especially palms

• 0
• 1
• 2
• 3

61. Dry or flaky skin and/or hair

• 0
• 1
• 2
• 3

62. History of gallbladder attacks or stones

• 0
• 1
• 2
• 3

63. Have you had your gallbladder removed?

• yes
• no

64. Category IX
Acne and unhealthy skin

• 0
• 1
• 2
• 3

65. Excessive hair loss

• 0
• 1
• 2
• 3

66. Overall sense of bloating

• 0
• 1
• 2
• 3

67. Bodily swelling for no reason

• 0
• 1
• 2
• 3

68. Hormone imbalances

• 0
• 1
• 2
• 3

69. Weight gain

• 0
• 1
• 2
• 3

70. Poor bowel function

• 0
• 1
• 2
• 3

71. Excessively foul-smelling sweat

• 0
• 1
• 2
• 3

72. Category X
Crave sweets during the day

• 0
• 1
• 2
• 3

73. Irritable if meals are missed

• 0
• 1
• 2
• 3

74. Depend on coffee to keep going/get started

• 0
• 1
• 2
• 3

75. Get light-headed if meals are missed

• 0
• 1
• 2
• 3

76. Eating relieves fatigue

• 0
• 1
• 2
• 3

77. Feel shaky, jittery, or have tremors

• 0
• 1
• 2
• 3

78. Agitated, easily upset, nervous

• 0
• 1
• 2
• 3

79. Poor memory, forgetful between meals

• 0
• 1
• 2
• 3

80. Blurred vision

• 0
• 1
• 2
• 3

81. Category XI
Fatigue after meals

• 0
• 1
• 2
• 3

82. Crave sweets during the day

• 0
• 1
• 2
• 3

83. Eating sweets does not relieve cravings for sugar

• 0
• 1
• 2
• 3

84. Must have sweets after meals

• 0
• 1
• 2
• 3

85. Waist girth is equal or larger than hip girth

• 0
• 1
• 2
• 3

86. Frequent urination

• 0
• 1
• 2
• 3

87. Increased thirst and appetite

• 0
• 1
• 2
• 3

88. Difficulty losing weight

• 0
• 1
• 2
• 3

89. Category XII
Cannot stay asleep

• 0
• 1
• 2
• 3

90. Crave salt

• 0
• 1
• 2
• 3

91. Slow starter in the morning

• 0
• 1
• 2
• 3

92. Afternoon fatigue

• 0
• 1
• 2
• 3

93. Dizziness when standing up quickly

• 0
• 1
• 2
• 3

94. Afternoon headaches

• 0
• 1
• 2
• 3

95. Headaches with exertion or stress

• 0
• 1
• 2
• 3

96. Weak nails

• 0
• 1
• 2
• 3

97. Category XIII
Cannot fall asleep

• 0
• 1
• 2
• 3

98. Perspire easily

• 0
• 1
• 2
• 3

99. Under a high amount of stress

• 0
• 1
• 2
• 3

100. Weight gain when under stress

• 0
• 1
• 2
• 3

101. Wake up tired even after 6 or more hours of sleep

• 0
• 1
• 2
• 3

102. Excessive perspiration or perspiration with little or no activity

• 0
• 1
• 2
• 3

103. Category XIV
Edema and swelling in ankles and wrists

• 0
• 1
• 2
• 3

104. Muscle cramping

• 0
• 1
• 2
• 3

105. Poor muscle endurance

• 0
• 1
• 2
• 3

106. Frequent urination

• 0
• 1
• 2
• 3

107. Frequent thirst

• 0
• 1
• 2
• 3

108. Crave salt

• 0
• 1
• 2
• 3

109. Abnormal sweating from minimal activity

• 0
• 1
• 2
• 3

110. Alteration in bowel regularity

• 0
• 1
• 2
• 3

111. Inability to hold breath for long periods

• 0
• 1
• 2
• 3

112. Shallow, rapid breathing

• 0
• 1
• 2
• 3

113. Category XV
Tired/sluggish

• 0
• 1
• 2
• 3

114. Feel cold―hands, feet, all over

• 0
• 1
• 2
• 3

115. Require excessive amounts of sleep to function properly

• 0
• 1
• 2
• 3

116. Increase in weight even with low-calorie diet

• 0
• 1
• 2
• 3

117. Gain weight easily

• 0
• 1
• 2
• 3

118. Difficult, infrequent bowel movements

• 0
• 1
• 2
• 3

119. Depression/lack of motivation

• 0
• 1
• 2
• 3

120. Morning headaches that wear off as the day progresses

• 0
• 1
• 2
• 3

121. Outer third of eyebrow thins

• 0
• 1
• 2
• 3

122. Thinning of hair on scalp, face, or genitals, or excessive hair loss

• 0
• 1
• 2
• 3

123. Dryness of skin and/or scalp

• 0
• 1
• 2
• 3

124. Mental sluggishness

• 0
• 1
• 2
• 3

125. Category XVI
Heart palpitations

• 0
• 1
• 2
• 3

126. Inward trembling

• 0
• 1
• 2
• 3

127. Increased pulse even at rest

• 0
• 1
• 2
• 3

128. Nervous and emotional

• 0
• 1
• 2
• 3

129. Insomnia

• 0
• 1
• 2
• 3

130. Night sweats

• 0
• 1
• 2
• 3

131. Difficulty gaining weight

• 0
• 1
• 2
• 3

132. Category XVII (Males Only)
Urination difficulty or dribbling

• 0
• 1
• 2
• 3

133. Frequent urination

• 0
• 1
• 2
• 3

134. Pain inside of legs or heels

• 0
• 1
• 2
• 3

135. Feeling of incomplete bowel emptying

• 0
• 1
• 2
• 3

136. Leg twitching at night

• 0
• 1
• 2
• 3

137. Category XVIII (Males Only)
Decreased libido

• 0
• 1
• 2
• 3

138. Decreased number of spontaneous morning erections

• 0
• 1
• 2
• 3

139. Decreased fullness of erections

• 0
• 1
• 2
• 3

140. Difficulty maintaining morning erections

• 0
• 1
• 2
• 3

141. Spells of mental fatigue

• 0
• 1
• 2
• 3

142. Inability to concentrate

• 0
• 1
• 2
• 3

143. Episodes of depression

• 0
• 1
• 2
• 3

144. Muscle soreness

• 0
• 1
• 2
• 3

145. Decreased physical stamina

• 0
• 1
• 2
• 3

146. Unexplained weight gain

• 0
• 1
• 2
• 3

147. Increase in fat distribution around chest and hips

• 0
• 1
• 2
• 3

148. Sweating attacks

• 0
• 1
• 2
• 3

149. More emotional than in the past

• 0
• 1
• 2
• 3

150. Category XIX (Menstruating Females Only)
Perimenopausal

• 0
• 1
• 2
• 3

151. Alternating menstrual cycle lengths

• yes
• no

152. Extended menstrual cycle (greater than 32 days)

• yes
• no

153. Shortened menstrual cycle (less than 24 days)

• yes
• no

154. Pain and cramping during periods

• 0
• 1
• 2
• 3

155. Scanty blood flow

• 0
• 1
• 2
• 3

156. Heavy blood flow

• 0
• 1
• 2
• 3

157. Breast pain and swelling during menses

• 0
• 1
• 2
• 3

158. Pelvic pain during menses

• 0
• 1
• 2
• 3

159. Irritable and depressed during menses

• 0
• 1
• 2
• 3

160. Acne

• 0
• 1
• 2
• 3

161. Facial hair growth

• 0
• 1
• 2
• 3

162. Hair loss/thinning

• 0
• 1
• 2
• 3

164. Since menopause, do you ever have uterine bleeding?

• yes
• no

165. Hot flashes

• 0
• 1
• 2
• 3

166. Mental fogginess

• 0
• 1
• 2
• 3

167. Disinterest in sex

• 0
• 1
• 2
• 3

168. Mood swings

• 0
• 1
• 2
• 3

169. Depression

• 0
• 1
• 2
• 3

170. Painful intercourse

• 0
• 1
• 2
• 3

171. Shrinking breasts

• 0
• 1
• 2
• 3

172. Facial hair growth

• 0
• 1
• 2
• 3

173. Acne

• 0
• 1
• 2
• 3

174. Increased vaginal pain, dryness, or itching

• 0
• 1
• 2
• 3

186. Neurotransmitter Assessment Form™
SECTION A
Is your memory noticeably declining?

• 0
• 1
• 2
• 3

187.  Are you having a hard time remembering names and phone numbers?

• 0
• 1
• 2
• 3

188. Is your ability to focus noticeably declining?

• 0
• 1
• 2
• 3

189. Has it become harder for you to learn new things?

• 0
• 1
• 2
• 3

190. How often do you have a hard time remembering your appointments?

• 0
• 1
• 2
• 3

191. Is your temperament generally getting worse?

• 0
• 1
• 2
• 3

192. Is your attention span decreasing?

• 0
• 1
• 2
• 3

193. How often do you find yourself down or sad?

• 0
• 1
• 2
• 3

194. How often do you become fatigued when driving compared to in the past?

• 0
• 1
• 2
• 3

195. How often do you become fatigued when reading compared to in the past?

• 0
• 1
• 2
• 3

196. How often do you walk into rooms and forget why?

• 0
• 1
• 2
• 3

197. How often do you pick up your cell phone and forget why?

• 0
• 1
• 2
• 3

198. SECTION B
How high is your stress level?

• 0
• 1
• 2
• 3

199. How often do you feel you have something that must be done?

• 0
• 1
• 2
• 3

200. Do you feel you never have time for yourself?

• 0
• 1
• 2
• 3

201. How often do you feel you are not getting enough sleep or rest?

• 0
• 1
• 2
• 3

202. Do you find it difficult to get regular exercise?

• 0
• 1
• 2
• 3

203. Do you feel uncared for by the people in your life?

• 0
• 1
• 2
• 3

204. Do you feel you are not accomplishing your life’s purpose?

• 0
• 1
• 2
• 3

205. Is sharing your problems with someone difficult for you?

• 0
• 1
• 2
• 3

206. SECTION C1
How often do you get irritable, shaky, or have light-headedness between meals?

• 0
• 1
• 2
• 3

207. How often do you feel energized after eating?

• 0
• 1
• 2
• 3

208. How often do you have difficulty eating large meals in the morning?

• 0
• 1
• 2
• 3

209. How often does your energy level drop in the afternoon?

• 0
• 1
• 2
• 3

210. How often do you crave sugar and sweets in the afternoon?

• 0
• 1
• 2
• 3

211. How often do you wake up in the middle of the night?

• 0
• 1
• 2
• 3

212. How often do you have difficulty concentrating before eating?

• 0
• 1
• 2
• 3

213. How often do you depend on coffee to keep yourself going?

• 0
• 1
• 2
• 3

214. How often do you feel agitated, easily upset, and nervous between meals?

• 0
• 1
• 2
• 3

215. SECTION C2
How often do you get fatigued after meals?

• 0
• 1
• 2
• 3

216. How often do you crave sugar and sweets after meals?

• 0
• 1
• 2
• 3

217. How often do you feel you need stimulants, such as coffee, after meals?

• 0
• 1
• 2
• 3

218. How often do you have difficulty losing weight?

• 0
• 1
• 2
• 3

219. How much larger is your waist girth compared to your hip girth?

• 0
• 1
• 2
• 3

220. How often do you urinate?

• 0
• 1
• 2
• 3

221. Have your thirst and appetite increased?

• 0
• 1
• 2
• 3

222. How often do you gain weight when under stress?

• 0
• 1
• 2
• 3

223. How often do you have difficulty falling asleep?

• 0
• 1
• 2
• 3

224. SECTION 1
Are you losing interest in hobbies?

• 0
• 1
• 2
• 3

225. How often do you feel overwhelmed?

• 0
• 1
• 2
• 3

226. How often do you have feelings of inner rage?

• 0
• 1
• 2
• 3

227. How often do you have feelings of paranoia?

• 0
• 1
• 2
• 3

228. How often do you feel sad or down for no reason?

• 0
• 1
• 2
• 3

229. How often do you feel like you are not enjoying life?

• 0
• 1
• 2
• 3

230. How often do you feel you lack artistic appreciation?

• 0
• 1
• 2
• 3

231. How often do you feel depressed in overcast weather?

• 0
• 1
• 2
• 3

232. How much are you losing your enthusiasm for your favorite activities?

• 0
• 1
• 2
• 3

233. How much are you losing your enjoyment for your favorite foods?

• 0
• 1
• 2
• 3

234. How much are you losing your enjoyment of friendships and relationships?

• 0
• 1
• 2
• 3

235. How often do you have difficulty falling into deep, restful sleep?

• 0
• 1
• 2
• 3

236. How often do you have feelings of dependency on others?

• 0
• 1
• 2
• 3

237. How often do you feel more susceptible to pain?

• 0
• 1
• 2
• 3

238. How often do you have feelings of unprovoked anger?

• 0
• 1
• 2
• 3

239. How much are you losing interest in life?

• 0
• 1
• 2
• 3

240. SECTION 2
How often do you have feelings of hopelessness?

• 0
• 1
• 2
• 3

241. How often do you have self-destructive thoughts?

• 0
• 1
• 2
• 3

242. How often do you have an inability to handle stress?

• 0
• 1
• 2
• 3

243. How often do you have anger and aggression while under stress?

• 0
• 1
• 2
• 3

244. How often do you feel you are not rested, even after long hours of sleep?

• 0
• 1
• 2
• 3

245. How often do you prefer to isolate yourself from others?

• 0
• 1
• 2
• 3

246. How often do you have unexplained lack of concern for family and friends?

• 0
• 1
• 2
• 3

247. How easily are you distracted from your tasks?

• 0
• 1
• 2
• 3

248. How often do you have an inability to finish tasks?

• 0
• 1
• 2
• 3

249. How often do you feel the need to consume caffeine to stay alert?

• 0
• 1
• 2
• 3

250. How often do you feel your libido has been decreased?

• 0
• 1
• 2
• 3

251. How often do you lose your temper for minor reasons?

• 0
• 1
• 2
• 3

252. How often do you have feelings of worthlessness?

• 0
• 1
• 2
• 3

253. SECTION 3
How often do you feel anxious or panicked for no reason?

• 0
• 1
• 2
• 3

254. How often do you have feelings of dread or impending doom?

• 0
• 1
• 2
• 3

255. How often do you feel knots in your stomach?

• 0
• 1
• 2
• 3

256. How often do you have feelings of being overwhelmed for no reason?

• 0
• 1
• 2
• 3

257. How often do you have feelings of guilt about everyday decisions?

• 0
• 1
• 2
• 3

258. How often does your mind feel restless?

• 0
• 1
• 2
• 3

259. How difficult is it to turn your mind off when you want to relax?

• 0
• 1
• 2
• 3

260. How often do you have disorganized attention?

• 0
• 1
• 2
• 3

261. How often do you worry about things you were not worried about before?

• 0
• 1
• 2
• 3

262. How often do you have feelings of inner tension and inner excitability?

• 0
• 1
• 2
• 3

263. SECTION 4
Do you feel your visual memory (shapes & images) has decreased?

• 0
• 1
• 2
• 3

264. Do you feel your verbal memory has decreased?

• 0
• 1
• 2
• 3

265. Do you have memory lapses?

• 0
• 1
• 2
• 3

266. Has your creativity decreased?

• 0
• 1
• 2
• 3

267. Has your comprehension diminished?

• 0
• 1
• 2
• 3

268. Do you have difficulty calculating numbers?

• 0
• 1
• 2
• 3

269. Do you have difficulty recognizing objects & faces?

• 0
• 1
• 2
• 3

270. Do you feel like your opinion about yourself has changed?

• 0
• 1
• 2
• 3

271. Are you experiencing excessive urination?

• 0
• 1
• 2
• 3

272. Are you experiencing a slower mental response?

• 0
• 1
• 2
• 3

273. SECTION 5
A decrease in mental alertness

• 0
• 1
• 2
• 3

274. A decrease in mental speed

• 0
• 1
• 2
• 3

275. A decrease in concentration quality

• 0
• 1
• 2
• 3

276. Slow cognitive processing

• 0
• 1
• 2
• 3

277. Impaired mental performance

• 0
• 1
• 2
• 3

278. Need coffee or caffeine sources to improve mental function

• 0
• 1
• 2
• 3

279. SECTION 6
How would you grade your Brain fog (if any)? 

• 0
• 1
• 2
• 3