Metabolic Screening Questionnaire
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Transcript of Metabolic Screening Questionnaire
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7/28/2019 Metabolic Screening Questionnaire
1/2
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 _____
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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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