Muscle Intelligence Coaching
Metabolic Assessment
[MIC - Client] Metabolic Assessment
Name
Email
Sex
Male
Female
Date
Part 1: Please list your 5 major health concerns in order of importance:
Part 1: Please list your 5 major health concerns in order of importance:
Health Concern 1
1.
Health Concern 2
2.
Health Concern 3
3.
Health Concern 4
4.
Health Concern 5
5.
Part 2: Please select the appropriate number on all questions below. 0 as the least / never, 3 as the most / always:
Category 1
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 2
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 3
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 4
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 & meats; undigested food found in stools
0
1
2
3
Category 5
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 6
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 7
Abdominal distention after consumption of fiber, starches, 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 8
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 9
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 10
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 11
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 12
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 13
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 14
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 15
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 16
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
Night sweats
0
1
2
3
Difficulty gaining weight
0
1
2
3
Category 17 (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 18 (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 19 (Menstruating Females Only)
Perimenopausal
Yes
No
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 20 (Menopausal Females Only)
How many years have you been menopausal?
Since menopause, do you ever have uterine bleeding?
Yes
No
Hot flashes
Yes
No
Mental fogginess
Yes
No
Disinterest in sex
Yes
No
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 3:
How many alcoholic beverages do you consume per week?
Rate your stress level on a scale of 1-10 during the average week:
How many caffeinated beverages do you consume per day?
How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work out per week?
How many times do you eat raw nuts or seeds per week?
List the three worst foods you eat during the average week:
Worst Food 1
1.
Worst Food 2
2.
Worst Food 3
3.
List the three healthiest foods you eat during the average week:
Healthy Food 1
1.
Healthy Food 2
2.
Healthy Food 3
3.
Part 4:
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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