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This FREE Metabolic Lifestyle Assessment is designed to aid us in assessing your potential need for a Nutrition & Lifestyle Program based upon your symptoms and current habits. The results can also used by any of your current & future health care practitioners to help them understand what you are dealing with at this time, so they can give you getter recommendations to improve your health & wellness.

Full Name *

Email *

Point of Scale:
0 = Never, or almost never have the same 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

Please ONLY enter a value between 0 - 4

Digestive

Nausea or vomiting : *

Diarrhea : *

Constipation : *

Bloated Feeling : *

Belching or passing gas : *

Heartburn : *

EARS

Itchy ears : *

Earaches, or ear infections : *

Drainage from ear : *

Ringing in ears, hearing loss : *

EMOTIONS

Mood swings : *

Anxiety, fear, or nervousness : *

Anger, irritability : *

Depression : *

Sense of despair : *

Uncaring or disinterested *

ENERGY / ACTIVITY

Fatigue or sluggishness : *

Hyperactivity : *

Restlessness : *

Insomnia : *

Startled awake at night : *

EYES

Watery or itchy eyes : *

Swollen, reddened, or sticky eyelids : *

Dark circles under eyes : *

Blurred or tunnel vision : *

HEAD

Headaches : *

Faintness : *

Dizziness : *

Pressure : *

LUNGS

Chest congestion : *

Asthma or bronchitis : *

Shortness of breath : *

Difficulty breathing : *

MIND

Poor memory : *

Confusion : *

Poor concentration : *

Poor coordination : *

Difficulty making decisions : *

Stuttering, stammering : *

Slurred speech : *

Learning disabilities : *

MOUTH/THROAT

Chronic coughing : *

Gagging or frequent need to clear throat : *

Swollen or discolored tongue, gums, lips : *

Canker sores : *

NOSE

Stuffy nose : *

Sinus problems : *

Hay fever : *

Sneezing attacks : *

Excessive mucous : *

SKIN

Acne : *

Hives, rashes, or dry skin : *

Hair loss : *

Flushing : *

Excessive sweating : *

HEART

Skipped heartbeats : *

Rapid heartbeats : *

Chest pain : *

JOINTS / MUSCLES

Pain or aches in joints : *

Rheumatoid arthritis : *

Osteoarthritis : *

Stiffness or limited movement : *

Pain or aches in muscles : *

Recurrent back aches : *

Feeling of weakness or tiredness : *

WEIGHT

Binge eating or drinking : *

Craving certain foods : *

Excessive weight : *

Compulsive eating : *

Water retention : *

Underweight : *

OTHER

Frequent illness : *

Frequent or urgent urination : *

Leaky bladder : *

Genital itch, discharge : *

SECTION II: RISK OF EXPOSURE

Rate each of the following situations based upon your environmental profile for the past 120 days.

a. How often are strong chemicals used in your home? *

b. How often are pesticides used in your home? *

c. How often do you have your home treated for insects? *

d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office? *

e. How often are you exposed to nail polish, perfume, hairspray, or other cosmetics? *

f. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes? *

a. Have you noticed any negative change in your health since you moved into your home or apartment? *

b. Have you noticed any change in your health since you started your new job? *

a. Do you have a water purification system in your home? *

b. Do you have any indoor pets? *

c. Do you have an air purification system in your home? *

d. Are you a dentist, painter, farm worker, or construction worker? *