Metabolic Screening Questionnaire

Instructions: Choose the response that best describes the Frequency and Severity of your symptoms.  Rate each of the following symptoms based on your typical health profile for the past 30 days.  Your results will be e-mailed to us for review.

Point Scale
0=Never or almost never have the symptom
1=Occasionally have it, effect is NOT SEVERE
2=Occasionally have it, effect is SEVERE
3=Frequently have it, effect is NOT SEVERE
4=Frequently have it, effect is SEVERE

 

     Metabolic Screening Questionnaire           Point Scale:

 

Head

0

1

2

3

4

1

Headaches

2

Faintness

3

Dizziness

4

Insomnia

 

 

 

 

 

 

 

 

Eyes

0

1

2

3

4

1

Watery or itchy eyes

2

Swollen, reddened or sticky eyelids

3

Bags or dark circles under eyes

4

Blurred or tunnel vision (does not include near- or far-sightedness)

 

 

 

 

 

 

 

 

Ears

0

1

2

3

4

1

Itchy ears

2

Earaches, ear infections

3

Drainage from ear

4

Ringing in ears, hearing loss

 

 

 

 

 

 

 

 

Nose

0

1

2

3

4

1

Stuffy nose

2

Sinus problems

3

Hay fever

4

Sneezing attacks

5

Excessive mucus formation

 

 

 

 

 

 

 

 

Mouth/Throat

0

1

2

3

4

1

Chronic coughing

2

Gagging, frequent need to clear throat

3

Sore throat, hoarseness, loss of voice

4

Swollen or discolored tongue, gums, lips

5

Canker sores

 

 

 

 

 

 

 

 

Skin

0

1

2

3

4

1

Acne

2

Hives, rashes, dry skin

3

Hair loss

4

Flushig, hot flashes

5

Excessive sweating

 

 

 

 

 

 

 

 

Heart

0

1

2

3

4

1

Irregular or skipping heartbeat

2

Rapid or pounding heartbeat

3

Chest pain

 

 

 

 

 

 

 

 

Lungs

0

1

2

3

4

1

Chest congestion

2

Asthma, bronchitis

3

Shortness of breath

4

Difficulty breathing

 

 

 

 

 

 

 

 

Digestive Tract

0

1

2

3

4

1

Nausea, vomiting

2

Diarrhea

3

Constipation

4

Bloated feeling

5

Belching, passing gas

6

Heartburn

7

Intestinal/stomach pain

 

 

 

 

 

 

 

 

Joints/Muscle

0

1

2

3

4

1

Pain or aches in joints

2

Arthritis

3

Stiffness or limitation of movement

4

Pain or aches in muscles

5

Feeling of weakness or tiredness

 

 

 

 

 

 

 

 

Weight

0

1

2

3

4

1

Binge eating/drinking

2

Craving certain foods

3

Excessive weight

4

Compulsive eating

5

Water retention

6

Underweight

 

 

 

 

 

 

 

 

Energy/Activity

0

1

2

3

4

1

Fatigue, sluggishness

2

Apathy, lethargy

3

Hyperactivity

4

Restlessness

 

 

 

 

 

 

 

 

Mind

0

1

2

3

4

1

Poor memory

2

Confusion, poor comprehension

3

Poor concentration

4

Poor physical coordination

5

Difficulty in making decisions

6

Stuttering or stammering

7

Slurred speech

8

Learning disabilities

 

 

 

 

 

 

 

 

Emotions

0

1

2

3

4

1

Mood swings

2

Anxiety, fear, nervousness

3

Anger, irritability, aggressiveness

4

Depression

 

 

 

 

 

 

 

 

Other

0

1

2

3

4

1

Frequent illness

2

Frequent or urgent urination

3

Genital itch or discharge

 

 

 

 

 

 

 

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