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Metabolic Assessment
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Category I: CH
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Feeling that bowels do not empty completely
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Lower abdominal pain relieved by passing stool or gas
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Alternating constipation and diarrhea
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Diarrhea
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Constipation
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Hard, dry, or small stool
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Coated tongue or “fuzzy” debris on tongue
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Pass large amount of foul-smelling gas
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More than 3 bowel movements daily
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Use laxatives frequently
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Category II: HC
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Excessive belching, burping or bloating
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Gas immediately following a meal
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Offensive breath
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Sense of fullness during and after meals
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Difficult bowel movements
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Difficulty digesting fruits and vegetables; undigested foods found in stools
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Category III: HA
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Stomach pain, burning or aching 1-4 hours after eating
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Use antacids
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Feel hungry and hour or two after eating
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Heartburn when lying down or bending forward
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Temporary relief by using antacids, food, milk or carbonated beverages
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Digestive problems subside with rest and relaxation
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Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine
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Category IV: SI
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Roughage and fiber cause constipation
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Indigestion and fullness last 2-4 hours after eating
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Pain, tenderness, soreness on left side under rib cage
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Excessive passage of gas
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Nausea and/or vomiting
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Frequent urination
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Stool undigested, foul smelling, mucous like, greasy, or poorly formed
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Increased thirst and appetite
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Difficulty losing weight
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Category V: BT
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Greasy or high fat foods cause distress
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Lower bowel gas and/or bloating several hours after eating
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Bitter metallic taste in mouth, especially in the morning
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Unexplained itchy skin
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Yellowish cast to eyes
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Stool color alternates from clay colored to normal brown
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Reddened skin, especially palms
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Dry or flaky skin and/or hair
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History of gallbladder attacks or stones
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Have you had your gall bladder removed?
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Category VI: HO
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Crave sweets during the day
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Irritable if meals are missed
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Depend on coffee to keep going/get started
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Get light-headed if meals are missed
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Eating relieves fatigue
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Feel shaky, jittery or have tremors
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Agitated, easily upset, nervous
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Poor memory/forgetful
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Blurred vision
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Category VII: IR
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Fatigue after meals
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Crave sweets during the day
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Eating sweets does not relieve cravings for sugar
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Must have sweets after meals
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Waist girth is equal to or larger than hip girth
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Frequent urination
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Increased thirst and appetite
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Difficulty losing weight
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Category VIII: AF
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Cannot stay asleep
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Crave salt
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Slow starter in the morning
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Afternoon fatigue
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Dizziness when standing up quickly
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Afternoon headaches
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Headaches with exertion or stress
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Weak nails
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Category IX: AH
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Cannot fall asleep
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Perspire easily
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Under high amount of stress
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Weight gain when under stress
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Wake up tired even after 6 or more hours of sleep
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Excessive perspiration or perspiration with little or no activity
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Category X: HoT
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Tired/sluggish
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Feel cold--hands, feet, all over
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Require excessive amounts of sleep to function properly
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Increase in weight even with low calorie diet
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Gain weight easily
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Difficult, infrequent bowel movements
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Depression/lack of motivation
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Morning headaches that wear off as the day progresses
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Outer third of eyebrow thins
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Thinning of hair on scalp, face, or genitals; excessive hair loss
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Dryness of skin and/or scalp
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Mental sluggishness
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Category XI: Thr
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Heart palpitations
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Inward trembling
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Increased pulse even at rest
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Nervous and emotional
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Insomnia
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Night sweats
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Difficulty gaining weight
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Category XII: Pho
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Diminished sex drive
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Menstrual disorders or lack of menstruation
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Increased ability to eat sugars without symptoms
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Category XIII: Phr
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Increased sex drive
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Tolerance to sugars reduced
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“Splitting”-type headaches
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Male Patients, Please Switch button to "On" and Fill Out
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Category XIV: PH
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Urination difficulty or dribbling
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Frequent urination
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Pain inside of legs or heels
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Feeling of incomplete bowel emptying
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Leg twitching at night
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Category XV: AP
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Decreased libido
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Decreased number of spontaneous morning erections
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Decreased fullness of erections
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Spells of mental fatigue
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Inability to concentrate
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Episodes of depression
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Muscle soreness
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Decreased physical stamina
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Unexplained weight gain
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Increase in fat distribution around chest and hips
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Sweating attacks
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More emotional than in past
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Menstruating Females Only switch button to "On" and fill out.
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Category XVI
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Premenopausal
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Alternating menstrual cycle lengths
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Extended menstrual cycle (greater than every 32 days)
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Shortened menstrual cycle (less than every 24 days)
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Pain and cramping during periods
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Scanty blood flow
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Heavy blood flow
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Breast pain and swelling during menses
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Pelvic pain during menses
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Irritable and depressed during menses
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Acne
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Facial hair growth
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Hair loss/thinning
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Menopausal Females Only switch button to "On" and fill out.
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Category XVII
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How many years have you been menopausal?
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Since menopause, do you ever have uterine bleeding?
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Hot flashes
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Mental fogginess
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Disinterest in sex
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Mood swings
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Depression
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Painful intercourse
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Shrinking breasts
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Facial hair growth
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Acne
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Increased vaginal pain, dryness or itching
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PART III
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How many alcoholic beverages do you consume per week?
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How many caffeinated beverages do you consumer per day?
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How many times do you eat out per week?
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How many times do you eat raw nuts or seeds per week?
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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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Rate your stress level on a scale from 1-10 during the average week:
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How many times do you eat fish per week?
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How many times to you work out per week?
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PART IV
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Please list any medications you currently take and for what condition:
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Please list any natural supplements you currently take and for what condition:
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