Sunday, April 23, 2017

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Any information that you submit using the form below will be encrypted, per HIPAA requirements. Your information shall be used for diagnostic purposes only. At no time will it be shared with any 3rd party at any time.

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The next stage is to complete your metabolic assessment.

Your Name: (Required)  
Email: (Required)    
Mailing address: (Required)  
Apt / Suite #:    
City: (Required)  
State: (Required)  
Zip code: (Required)  
Day phone: (Required)  
Time zone: (Required)  
Sex: (Required)  
Age: (Required)  
DOB: (Required)  
Height: (Required)  
Weight: (Required)  
LabCorp location  where your blood will be drawn: (Required)  
Date you will have your blood drawn: (Required)  
  Please list five major health concerns in your order of importance:
1.  (Required)  
2.  (Required)  
3.  (Required)  
4.  (Required)  
5.  (Required)  
  Please select the appropriate number from 0 to 3 for each question, with 0 as the least or never, and 3 as the most or always.

Category I

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

Category II

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 foods found in stool

Category III

Stomach pain, burning, or aching 1-4 hours after eating
Do you frequently use antacids?
Feeling hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief from antacids, food, milk, carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine

Category IV

Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours
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
Difficulty losing weight

Category V

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
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 VI

Irritable if meals are missed
Depend on coffee to keep yourself going or started
Get lightheaded if meals are missed
Eating relieves fatigue
Feel shaky, jittery, tremors
Agitated, easily upset, nervous
Poor memory, forgetful
Blurred vision

Category VII

Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal to or greater than hip girth
Frequent urination
Increased thirst and appetite
Difficult losing weight

Category VIII

Cannot 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 IX

Cannot fall asleep
Perspire easily
Under high amounts of stress
Weight gain when under stress
Wake up tired even after six or more hours of sleep
Excessive perspiration or perspiration with little or no activity

Category X

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

Category IX

Heart palpatations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight

Category XII

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

Category XIII

Increased sex drive
Tolerance to sugars reduced
Splitting type headaches

Category XIV (Males only)

Urination difficult or dribbling
Urination frequent
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night

Category XV (Males only)

Decrease in libido
Decrease in spontaneous morning erections
Decrease in fullness of erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decrease in physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past

Category XVI (Menstruating females only)

Are you perimenopausal?
Alternating menstrual cycle lengths
Extended menstrual cycle, greater than 32 days
Shortened menses, less than every 24 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 breaks out
Facial hair growth
Hair loss/thinning

Category XVII (Menopausal females only)

How many year 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
How many alcoholic beverages to 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 work out ?
  List the three worst foods you eat during the average week
1.     
2.     
3.     
  List the three healthiest foods you eat during the average week:
1.     
2.     
3.     
Do you smoke?    
If yes how many times a day?    
Rate your stress level 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    
 
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