7/28/2019 Metabolic Screening Questionnaire

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Alder Brooke Healing ArtsMetabolic Screening Questionnaire

Client Name: ______________________ Date: _________

Rate each of the following symptoms based upon your typical health profile.

INITIAL TEST RETEST- Initial Test Date ___________Point Scale: 0 = Never or almost never have the symptom

1 = Occasionally have it, effect is not severe2 = Occasionally have it, effect is severe3 = Frequently have it, effect is not severe4 = Frequently have it, effect is severe

HEAD____Headaches____Faintness____Dizziness____Insomnia

Total _____

MOUTH/THROAT____Chronic coughing____Gagging, frequent need to clear

throat____Sore throat, hoarseness, loss of

voice____Swollen or discolored tongue, gums

or lips

Total _____EYES

____Watery or itchy eyes

____Swollen, reddened or sticky eyelids____Bags or dark circles under eyes____Blurred or tunnel vision

Total _____

SKIN____Acne

____Hives, rashes, dry skin____Hair loss____Flushing, hot flashes____Excessive sweating

Total _____EARS

____Itchy Ears____Earaches, ear infections____Drainage from ear____Ringing in ears, hearing loss

Total _____

HEART____Irregular or skipped heartbeat____Rapid or pounding heartbeat____Chest pain

Total _____NOSE

____Stuffy nose____Sinus problems____Hay fever____Sneezing attacks____Excessive mucus formation

Total _____

LUNGS____Chest congestion____Asthma, bronchitis____Shortness of breath____Difficulty breathing

Total _____

7/28/2019 Metabolic Screening Questionnaire

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Point Scale: 0 = Never or almost never have the symptom1 = Occasionally have it, effect is not severe2 = Occasionally have it, effect is severe3 = Frequently have it, effect is not severe4 = Frequently have it, effect is severe

DIGESTIVE TRACT

____Nausea, vomiting____Diarrhea____Constipated____Bloated feeling____Belching, passing gas____Heartburn____Intestinal/stomach pain

Total _____

ENERGY/ACTIVITY

____Fatigue, sluggishness____Apathy, lethargy____Hyperactivity____Restlessness

Total _____JOINTS/MUSCLES

____Pain or aches in joint

____Arthritis____Stiffness or limitation of movement____Pain or aches in muscles____Feeling of weakness or tiredness

Total _____

MINDS____Poor memory

____Confusion, poor comprehension____Poor concentration____Difficulty in making decisions____Stuttering or stammering____Slurred speech____Learning disabilities

Total _____WEIGHT

____Binge eating/drinking

____Craving certain foods____Excessive weight____Compulsive eating____Water retention____Underweight

Total _____

EMOTIONS____Mood swings

____Anxiety, fear, nervousness____Anger, irritability, aggressiveness____Depression

Total _____OTHER

____Frequent illness____Frequent or urgent urination____General itch or discharge

Total _____ GRAND TOTAL _____

Notes: ______________________________________________________________________

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