New Patient Information Forms

Metabolic Assessment Form

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PART I

Please list your 5 major health concerns in order of importance:

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PART II

Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely

0 1 2 3

Lower abdominal pain relieved by passing stool or gas

0 1 2 3

Alternating constipation and diarrhea

0 1 2 3

Diarrhea

0 1 2 3

Constipation

0 1 2 3

Hard, dry, or small stool

0 1 2 3

Coated tongue or “fuzzy” debris on tongue

0 1 2 3

Pass large amount of foul-smelling gas

0 1 2 3

More than 3 bowel movements daily

0 1 2 3

Use laxatives frequently

0 1 2 3

Category II

Increasing frequency of food reactions

0 1 2 3

Unpredictable food reactions

0 1 2 3

Aches, pains, and swelling throughout the body

0 1 2 3

Unpredictable abdominal swelling

0 1 2 3

Frequent bloating and distention after eating

0 1 2 3

Category III

Intolerance to smells

0 1 2 3

Intolerance to jewelry

0 1 2 3

Intolerance to shampoo, lotion, detergents, etc

0 1 2 3

Multiple smell and chemical sensitivities

0 1 2 3

Constant skin outbreaks

0 1 2 3

Category IV

Excessive belching, burping, or bloating

0 1 2 3

Gas immediately following a meal

0 1 2 3

Offensive breath

0 1 2 3

Difficult bowel movements

0 1 2 3

Sense of fullness during and after meals

0 1 2 3

Difficulty digesting proteins and meats; undigested food found in stools

0 1 2 3

Category V

Stomach pain, burning, or aching 1-4 hours after eating

0 1 2 3

Use of antacids

0 1 2 3

Feel hungry an hour or two after eating

0 1 2 3

Heartburn when lying down or bending forward

0 1 2 3

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

0 1 2 3

Digestive problems subside with rest and relaxation

0 1 2 3

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

0 1 2 3

Category VI

Difficulty digesting roughage and fiber

0 1 2 3

Indigestion and fullness last 2-4 hours after eating

0 1 2 3

Pain, tenderness, soreness on left side under rib cage

0 1 2 3

Excessive passage of gas

0 1 2 3

Nausea and/or vomiting

0 1 2 3

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

0 1 2 3

Frequent loss of appetite

0 1 2 3

Category VII

Abdominal distention after consumption of fiber, starches, and sugar

0 1 2 3

Abdominal distention after certain probiotic or natural supplements

0 1 2 3

Decreased gastrointestinal motility, constipation

0 1 2 3

Increased gastrointestinal motility, diarrhea

0 1 2 3

Alternating constipation and diarrhea

0 1 2 3

Suspicion of nutritional malabsorption

0 1 2 3

Frequent use of antacid medication

0 1 2 3

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

Yes No

Category VIII

Greasy or high-fat foods cause distress

0 1 2 3

Lower bowel gas and/or bloating several hours after eating

0 1 2 3

Bitter metallic taste in mouth, especially in the morning

0 1 2 3

Burpy, fishy taste after consuming fish oils

0 1 2 3

Unexplained itchy skin

0 1 2 3

Yellowish cast to eyes

0 1 2 3

Stool color alternates from clay colored to normal brown

0 1 2 3

Reddened skin, especially palms

0 1 2 3

Dry or flaky skin and/or hair

0 1 2 3

History of gallbladder attacks or stones

0 1 2 3

Have you had your gallbladder removed?

Yes No

Category IX

Acne and unhealthy skin

0 1 2 3

Excessive hair loss

0 1 2 3

Overall sense of bloating

0 1 2 3

Bodily swelling for no reason

0 1 2 3

Hormone imbalances

0 1 2 3

Weight gain

0 1 2 3

Poor bowel function

0 1 2 3

Excessively foul-smelling sweat

0 1 2 3

Category X

Crave sweets during the day

0 1 2 3

Irritable if meals are missed

0 1 2 3

Depend on coffee to keep going/get started

0 1 2 3

Get light-headed if meals are missed

0 1 2 3

Eating relieves fatigue

0 1 2 3

Feel shaky, jittery, or have tremors

0 1 2 3

Agitated, easily upset, nervous

0 1 2 3

Poor memory, forgetful between meals

0 1 2 3

Blurred vision

0 1 2 3

Category XI

0 1 2 3

Fatigue after meals

0 1 2 3

Crave sweets during the day

0 1 2 3

Eating sweets does not relieve cravings for sugar

0 1 2 3

Must have sweets after meals

0 1 2 3

Waist girth is equal or larger than hip girth

0 1 2 3

Frequent urination

0 1 2 3

Increased thirst and appetite

0 1 2 3

Difficulty losing weight

0 1 2 3

Category XII

Cannot stay asleep

0 1 2 3

Crave salt

0 1 2 3

Slow starter in the morning

0 1 2 3

Afternoon fatigue

0 1 2 3

Dizziness when standing up quickly

0 1 2 3

Afternoon headaches

0 1 2 3

Headaches with exertion or stress

0 1 2 3

Weak nails

0 1 2 3

Category XIII

Cannot fall asleep

0 1 2 3

Perspire easily

0 1 2 3

Under a high amount of stress

0 1 2 3

Weight gain when under stress

0 1 2 3

Wake up tired even after 6 or more hours of sleep

0 1 2 3

Excessive perspiration or perspiration with little or no activity

0 1 2 3

Category XIV

Edema and swelling in ankles and wrists

0 1 2 3

Muscle cramping

0 1 2 3

Poor muscle endurance

0 1 2 3

Frequent urination

0 1 2 3

Frequent thirst

0 1 2 3

Crave salt

0 1 2 3

Abnormal sweating from minimal activity

0 1 2 3

Alteration in bowel regularity

0 1 2 3

Inability to hold breath for long periods

0 1 2 3

Shallow, rapid breathing

0 1 2 3

Category XV

Tired/sluggish

0 1 2 3

Feel cold―hands, feet, all over

0 1 2 3

Require excessive amounts of sleep to function properly

0 1 2 3

Increase in weight even with low-calorie diet

0 1 2 3

Gain weight easily

0 1 2 3

Difficult, infrequent bowel movements

0 1 2 3

Depression/lack of motivation

0 1 2 3

Morning headaches that wear off as the day progresses

0 1 2 3

Outer third of eyebrow thins

0 1 2 3

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

0 1 2 3

Dryness of skin and/or scalp

0 1 2 3

Mental sluggishness

0 1 2 3

Category XVI

Heart palpitations

0 1 2 3

Inward trembling

0 1 2 3

Increased pulse even at rest

0 1 2 3

Nervous and emotional

0 1 2 3

Insomnia

0 1 2 3

Category XVI (Cont.)

Night sweats

0 1 2 3

Difficulty gaining weight

0 1 2 3

Category XVII (Males Only)

Urination difficulty or dribbling

0 1 2 3

Frequent urination

0 1 2 3

Pain inside of legs or heels

0 1 2 3

Feeling of incomplete bowel emptying

0 1 2 3

Leg twitching at night

0 1 2 3

Category XVIII (Males Only)

Decreased libido

0 1 2 3

Decreased number of spontaneous morning erections

0 1 2 3

Decreased fullness of erections

0 1 2 3

Difficulty maintaining morning erections

0 1 2 3

Spells of mental fatigue

0 1 2 3

Inability to concentrate

0 1 2 3

Episodes of depression

0 1 2 3

Muscle soreness

0 1 2 3

Decreased physical stamina

0 1 2 3

Unexplained weight gain

0 1 2 3

Increase in fat distribution around chest and hips

0 1 2 3

Sweating attacks

0 1 2 3

More emotional than in the past

0 1 2 3

Category XIX (Menstruating Females Only)

Perimenopausal

Yes On

Alternating menstrual cycle lengths

Yes No

Extended menstrual cycle (greater than 32 days)

Yes No

Shortened menstrual cycle (less than 24 days)

Yes No

Pain and cramping during periods

0 1 2 3

Scanty blood flow

0 1 2 3

Heavy blood flow

0 1 2 3

Breast pain and swelling during menses

0 1 2 3

Pelvic pain during menses

0 1 2 3

Irritable and depressed during menses

0 1 2 3

Acne

0 1 2 3

Facial hair growth

0 1 2 3

Hair loss/thinning

0 1 2 3

Category XX (Menopausal Females Only)

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Since menopause, do you ever have uterine bleeding?

Yes No

Hot flashes

0 1 2 3

Mental fogginess

0 1 2 3

Disinterest in sex

0 1 2 3

Mood swings

0 1 2 3

Depression

0 1 2 3

Painful intercourse

0 1 2 3

Shrinking breasts

0 1 2 3

Facial hair growth

0 1 2 3

Acne

0 1 2 3

Increased vaginal pain, dryness, or itching

0 1 2 3

PART III

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List the three worst foods you eat during the average week

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List the three healthiest foods you eat during the average week

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PART IV

Please list any medications you currently take and for what conditions

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Please list any natural supplements you currently take and for what conditions

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Brain Region Localization Form

INSTRUCTIONS:

The purpose of this questionnaire is to identify difficulties

that you may be experiencing. Please answer every

question, do not skip any questions. Follow the 0 to 4 key,

and select which best fits for all of your answers.

KEY:

0 = I never have symptoms (0% of the time)

1 = I rarely have symptoms (Less than 25% of the time)

2 = I often have symptoms (Half of the time)

3 = I frequently have symptoms (75% of the time)

4 = I always have symptoms (100% of the time)

Frontal lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11, and 12)

Difficulty with restraint and controlling impulses or desires

0 1 2 3 4

Emotional instability (lability)

0 1 2 3 4

Difficulty planning and organizing

0 1 2 3 4

Difficulty making decisions

0 1 2 3 4

Lack of motivation, enthusiasm, interest and drive (apathetic)

0 1 2 3 4

Difficulty getting a sound or melody out of your thoughts (Perseveration)

0 1 2 3 4

Constantly repeat events or thoughts with difficulty letting go

0 1 2 3 4

Difficulty initiating and finishing tasks

0 1 2 3 4

Episodes of depression

0 1 2 3 4

Mental fatigue

0 1 2 3 4

Decrease in attention span

0 1 2 3 4

Difficulty staying focused and concentrating for extended periods of time

0 1 2 3 4

Difficulty with creativity, imagination, and intuition

0 1 2 3 4

Difficulty in appreciating art and music

0 1 2 3 4

Difficulty with analytical thought

0 1 2 3 4

Difficulty with math, number skills and time consciousness

0 1 2 3 4

Difficulty taking ideas, actions, and words and putting them in a linear sequence

0 1 2 3 4

Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 6)

Initiating movements with your arm or leg has become more difficult

0 1 2 3 4

Feeling of arm or leg heaviness, especially when tired

0 1 2 3 4

Increased muscle tightness in your arm or leg

0 1 2 3 4

Reduced muscle endurance in your arm or leg

0 1 2 3 4

Noticeable difference in your muscle function or strength from one side to the other

0 1 2 3 4

Noticeable difference in your muscle tightness from one side to the other

0 1 2 3 4

Frontal Lobe Broca’s Motor Speech Area (Area 44 and 45)

Difficulty producing words verbally, especially when fatigued

0 1 2 4 5

Find the actual act of speaking difficult at times

0 1 2 3 4

Notice word pronunciation and speaking fluency change at times

0 1 2 3 4

Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3,1,2 and 7)

Difficulty in perception of position of limbs

0 1 2 3 4

Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall

0 1 2 3 4

Frequently bumping body or limbs into the wall or objects accidently

0 1 2 3 4

Reoccurring injury in the same body part or side of the body

0 1 2 3 4

Hypersensitivities to touch or pain perception

0 1 2 3 4

Parietal Inferior Lobule (Area 39 and 40)

Right/left confusion

0 1 2 3 4

Difficulty with math calculations

0 1 2 3 4

Difficulty finding words

0 1 2 3 4

Difficulty with writing

0 1 2 3 4

Difficulty recognizing symbols or shapes

0 1 2 3 4

Difficulty with simple drawings

0 1 2 3 4

Difficulty interpreting maps

0 1 2 3 4

Temporal Lobe Auditory Cortex (Areas 41, 42)

Reduced function in overall hearing

0 1 2 3 4

Difficulty interpreting speech with background or scatter noise

0 1 2 3 4

Difficulty comprehending language without perfect pronunciation

0 1 2 3 4

Need to look at someone’s mouth when they are speaking to understand what they are saying

0 1 2 3 4

Difficulty in localizing sound

0 1 2 3 4

Dislike of left predictable rhythmic, repeated tempo and beat music

0 1 2 3 4

Dislike of non-predictable rhythmic with multiple instruments

0 1 2 3 4

. Noticeable ear preference when using your phone

Right Left No

Temporal Lobe Auditory Association Cortex (Area 22)

Difficulty comprehending meaning of spoken word

0 1 2 3 4

Tend toward monotone speech without fluctuations or emotions

0 1 2 3 4

Medial Temporal lobe and Hippocampus

Memory less efficient

0 1 2 3 4

Memory loss that impacts daily activities

0 1 2 3 4

Confusion about dates, the passage of time, or place

0 1 2 3 4

Difficulty remembering events

0 1 2 3 4

Misplacement of things and difficulty retracing steps

0 1 2 3 4

Difficulty with memory of locations (addresses)

0 1 2 3 4

Difficulty with visual memory

0 1 2 3 4

Always forgetting where you put items such as keys, wallet, phone, etc.

0 1 2 3 4

Difficulty remembering faces

0 1 2 3 4

Difficulty remembering names with faces

0 1 2 3 4

Difficulty with remembering words

0 1 2 3 4

Difficulty remembering numbers

0 1 2 3 4

Difficulty remembering to stay or be on time

0 1 2 3 4

Occipital Lobe (Area, 17, 18, and 19)

Difficulty in discriminating similar shades of color

0 1 2 3 4

Dullness of colors in visual field

0 1 2 3 4

Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects

0 1 2 3 4

Floater or halos in visual field

0 1 2 3 4

Cerebellum - Spinocerebellum

Difficulty with balance, or balance that is worse on one side

0 1 2 3 4

A need to hold the handrail or watch each step carefully when going down stairs

0 1 2 3 4

Feeling unsteady and prone to falling in the dark

0 1 2 3 4

Proness to sway to one side when walking or standing

0 1 2 3 4

Cerebellum - Cerebrocerebellum

Recent clumsiness in hands

0 1 2 3 4

Recent clumsiness in feet or frequent tripping

0 1 2 3 4

A slight hand shake when reaching for something at the end of movement

0 1 2 3 4

Cerebellum - Vestibulocerebellum

Episodes of dizziness or disorientation

0 1 2 3 4

Back muscles that tire quickly when standing or walking

0 1 2 3 4

Chronic neck or back muscle tightness

0 1 2 3 4

Nausea, car sickness, or sea sickness

0 1 2 3 4

Feeling of disorientation or shifting of the environment

0 1 2 3 4

Crowded places cause anxiety

0 1 2 3 4

Basal Ganglia Direct Pathway

Slowness in movements

0 1 2 3 4

Stiffness in your muscles (not joints) that goes away when you move

0 1 2 3 4

Cramping of hands when writing

0 1 2 3 4

A stooped posture when walking

0 1 2 3 4

Voice has become softer

0 1 2 3 4

Facial expression changed leading people to frequently ask if you are upset or angry

0 1 2 3 4

Basal Ganglia Indirect Pathway

Uncontrollable muscle movements

0 1 2 3 4

Intense need to clear your throat regularly or contract a group of muscles

0 1 2 3 4

Obsessive compulsive tendencies

0 1 2 3 4

Constant nervousness and restless mind

0 1 2 3 4

Autonomic Reduced Parasympathetic Activity

Dry mouth or eyes

0 1 2 3 4

Difficulty swallowing supplements or large bites of food

0 1 2 3 4

Slow bowel movements and tendency for constipation

0 1 2 3 4

Chronic digestive complaints

0 1 2 3 4

Bowel or bladder incontinence resulting in staining your underwear

0 1 2 3 4

Autonomic Increased Sympathetic Activity

Tendency for anxiety

0 1 2 3 4

Easily startled

0 1 2 3 4

Difficulty relaxing

0 1 2 3 4

Sensitive to bright or flashing lights

0 1 2 3 4

Episodes of racing heart

0 1 2 3 4

Difficulty sleeping

0 1 2 3 4

Call today:

Location

Main Location

Metabolic Assessment Form

PART I

PART II

Category I

Category II

Category III

Category IV

Category V

Category VI

Category VII

Category VIII

Category IX

Category X

Category XII

Category XIII

Category XIV

Category XV

Category XVI

Category XVI (Cont.)

Category XVII (Males Only)

Category XVIII (Males Only)

Category XIX (Menstruating Females Only)

Category XX (Menopausal Females Only)

PART III

PART IV

Brain Region Localization Form

Frontal lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11, and 12)

Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 6)

Frontal Lobe Broca’s Motor Speech Area (Area 44 and 45)

Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3,1,2 and 7)

Parietal Inferior Lobule (Area 39 and 40)

Temporal Lobe Auditory Cortex (Areas 41, 42)

Temporal Lobe Auditory Association Cortex (Area 22)

Medial Temporal lobe and Hippocampus

Occipital Lobe (Area, 17, 18, and 19)

Cerebellum - Spinocerebellum

Cerebellum - Cerebrocerebellum

Cerebellum - Vestibulocerebellum

Basal Ganglia Direct Pathway

Basal Ganglia Indirect Pathway

Autonomic Reduced Parasympathetic Activity

Autonomic Increased Sympathetic Activity

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