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Metabolic Health Assessment

Patient Name*
Directions: Rate each of the following based upon your typical health profile:
1. Occasionally have symptom
2. Frequently have symptom, not severe
3. Frequently have symptom, effect is severe,
List Top 4 Health Concerns
1. Thyroid Symptoms
*Difficulty gaining weight, even with large appetite
- 1
- 2
- 3
*Nervous, emotional, can’t work under pressure
- 1
- 2
- 3
*Flush easily
- 1
- 2
- 3
*Fast pulse at rest
- 1
- 2
- 3
*Inward trembling
- 1
- 2
- 3
*Intolerance - high temperatures
- 1
- 2
- 3
Difficulty losing weight
- 1
- 2
- 3
Mentally sluggish, reduced initiative
- 1
- 2
- 3
Easily fatigued, sleepy during the day
- 1
- 2
- 3
Sensitive to cold, poor circulation (cold hands and feet)
- 1
- 2
- 3
Excessive hair loss and/or coarse hair
- 1
- 2
- 3
Morning headaches, wear off during the day
- 1
- 2
- 3
Loss of lateral 1/3 of eyebrow
- 1
- 2
- 3
Infrequent bowel movements
- 1
- 2
- 3
(*) Referring to Hyperthyroid
2. Sugar Handling Symptoms
Crave sweets
- 1
- 2
- 3
Irritable if missed meals
- 1
- 2
- 3
Light headed if meals are missed
- 1
- 2
- 3
Frequent urination
- 1
- 2
- 3
Frequent thirst
- 1
- 2
- 3
Fatigue after meals
- 1
- 2
- 3
Eating relieves fatigue
- 1
- 2
- 3
Agitated or easily upset
- 1
- 2
- 3
Blurred vision
- 1
- 2
- 3
Headache if meals are missed
- 1
- 2
- 3
Poor memory/forgetful
- 1
- 2
- 3
Shaky if missed meals
- 1
- 2
- 3
Binge or uncontrolled eating
- 1
- 2
- 3
3. Adrenal Symptoms
*Cannot fall asleep; wake up after a few hours of sleep
- 1
- 2
- 3
*Perspire easily
- 1
- 2
- 3
*Wake up tired – after 6+ hours of sleep
- 1
- 2
- 3
*Tend to be “keyed up” during the day
- 1
- 2
- 3
*Clenched or grind teeth
- 1
- 2
- 3
*Excessive thirst
- 1
- 2
- 3
Crave salty foods
- 1
- 2
- 3
Cannot stay asleep. Awaken after a few hours of sleep
- 1
- 2
- 3
Slow starter in the morning
- 1
- 2
- 3
Afternoon fatigue
- 1
- 2
- 3
Become dizzy when standing up suddenly
- 1
- 2
- 3
Weak nails
- 1
- 2
- 3
Weakness / Dizziness
- 1
- 2
- 3
Afternoon yawning
- 1
- 2
- 3
Allergies or hives
- 1
- 2
- 3
Arthritic tendencies
- 1
- 2
- 3
(*) Referring to Hyperadrenal
4. Environmental Symptoms
Chemical & odor sensitivities
- 1
- 2
- 3
Headaches after exposure to chemicals
- 1
- 2
- 3
Intolerance to household chemicals (e.g. shampoo, lotion, laundry detergent, etc.)
- 1
- 2
- 3
Skin outbreaks
- 1
- 2
- 3
Excessive mucus
- 1
- 2
- 3
5. Leaky Gut Symptoms
Bloating and distention after eating
- 1
- 2
- 3
Intolerance to sugars & starches - upset the stomach
- 1
- 2
- 3
Abdominal swelling
- 1
- 2
- 3
Increased reactions to eating foods
- 1
- 2
- 3
Pains, aches and swelling throughout the body
- 1
- 2
- 3
Unpredictable food reactions
- 1
- 2
- 3
Skin issues: acne, rosacea
- 1
- 2
- 3
6. Digestion Symptoms
Bad breath (halitosis)
- 1
- 2
- 3
Heartburn or acid reflux
- 1
- 2
- 3
Excessive belching or burping
- 1
- 2
- 3
Undigested foods in stool
- 1
- 2
- 3
Gas after meals
- 1
- 2
- 3
Difficult bowel movements
- 1
- 2
- 3
Sense of excess fullness after meals
- 1
- 2
- 3
Sense of excess fullness after meals
- 1
- 2
- 3
7. Liver & Gallbladder
Nausea
- 1
- 2
- 3
Hormone imbalances
- 1
- 2
- 3
Light colored stools
- 1
- 2
- 3
Pain between shoulder blades
- 1
- 2
- 3
Stomach upset after greasy foods
- 1
- 2
- 3
Acne or unhealthy skin
- 1
- 2
- 3
Hemorrhoids or varicose veins
- 1
- 2
- 3
Dry or flakey skin
- 1
- 2
- 3
Itchy skin
- 1
- 2
- 3
Removal of gallbladder
- 1
- 2
- 3
Gallbladder attacks
- 1
- 2
- 3
Headache over eyes
- 1
- 2
- 3
Category 1: Thyroid Symptoms
GTA Forte (High TSH >3.0)
Thyrostim (Low TSH <1.8). Source of vitamins, minerals and Pituitary support
Cytozyme PT/HPT (low TSH). Pituitary and Hypothalmus support
MedaStim: Converts T4 to T3. Conversion takes place in the Liver, Lungs & Kidneys
Note: Mixed hyper and hypothyroid symptoms; run TPO and Thyroglobulin antibodies to rule out autoimmune.
Category 2: Blood Sugar Symptoms
GlucoBalance (High blood sugar >99)
Bio-Glycozyme (Low blood sugar <85)
Category 3: Adrenal Symptoms
ADHS with high blood sugar (Phase 1 Adrenal Fatigue-Salivary Cortisol levels are high)
ADB-5 Plus (Phase 3 Adrenal Fatigue-Salivary Cortisol levels are low)
Cytozyme-AD for everyone else
Category 4: Environmental Symptoms
Note: Specialized testing first
Bio-D-Mulsion Forte: 2000IU per drop
ScentArest: Key nutrients to up-regulate clearance
Kapparest: Anti-inflammatory
ReservaSirt-HP (Trans resveratrol):Anti-inflammatory and stimulates sirtuin enzymes.
Livotrit (Ayurvedic formulation): Liver Phase 1 & 2 detoxification
Note: For Heavy Metals: (Porphyra-Zyme, Chlorella Caps)
Category 5: Leaky Gut Symptoms
L-Glutamine Powder or L-Glutamine Caps: Anti-inflammatory an cellular energy
Butyric Cal-Mag: Colon and tight junction membrane support
Bromelain Plus CLA: Lactose free digestive enzyme
GSH: Immune support
Bio-D-Mulsion Forte: 2000 IU per drop
Category 6: Digestion Symptoms
Hydrozyme: HCl therapy
Betaine Plus HP (700 mg of Betaine Hydrochloride):
Strongest of HCL therapy
Bromelain Plus CLA (Plant based digestive enzymes):
Lactose Free digestive enzyme
Category 7: Liver & Gallbaladder Symptoms
Livotrit (Ayurvedic formulation): Phase 1 & 2 liver detoxification
Beta TCP: Gallbladder support with 100 mg of organic beets per tablet. Taurine for fat metabolism
BetaPlus: Gallballder support with ox bile and organic beets.
Cytozyme-LV: Neonatal extract to support Liver
Methylfolate Plus (800 mcg of MTHF) or 5-MTHF Plus Forte (5000 mcg of 5-MTHF)
Add up the numbers to arrive at a total for each section. Then add the totals for each section to arrive at a grand total. If any individual section total is 10 or more, or the grand total is 14 or more, you may benefit from the 3-Step Bio Detoxification program.
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