PATIENT METABOLIC SCREENING QUESTIONNAIRE

Name:
Address:
Telephone:
Date of Birth:
Sex:
Date:

THIS MUST BE COMPLETED BEFORE YOUR EXAMINATION CAN PROCEED

Rate each of the following symptoms based upon your health profile for the past 30 days

POINT SCALE

0 = Never or almost never have the 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


DIGESTIVE TRACT
Bloated Feeling
Belching, or passing gas
Heartburn
Intestinal/Stomach Pain
Total :

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EARS
Itchy Ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total :

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EMOTIONS
Mood swings
Anxiety, fear or nervousness
Anger, irritability, or aggressiveness
Depression
Total :

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ENERGY/ACTIVITY
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total :

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EYES
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not include near- or far-sightedness)
Total :

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HEAD
Headaches
Faintness
Dizziness
Insomnia
Total :

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HEART
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Total :

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JOINTS/MUSCLES
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Total :

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LUNGS
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total :

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MIND
Poor Memory
Confusion, poor comprehension
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total :

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MOUTH/THROAT
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discoloured tongue, gums, lips
Canker Sores
Total :

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NOSE
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total :

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SKIN
Acne
Hives, rashes, or dry skin
Hair loss
Flushing or hot flushes
Excessive sweating
Total :

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WEIGHT
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Total :

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OTHER
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total :

GRAND TOTAL:

COMMENTS:

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PLEASE ANSWER THE FOLLOWING QUESTIONS BY SELECTING THE MOST APPROPRIATE ANSWER.

1. Have you been treated with antibiotics?
2. Have you ever had problems with yeast infections?
No
Yes
3. Do you eat or crave a lot of sweet foods?
No
Yes
4. Do you have a problem with food allergies?
No
Yes
5. Have you suffered from any food poisoning? No Yes
6. Do you or have you consumed alcohol on a regular basis? No Yes
7. Have you ever taken the drugs Tagamet or Zantac? No Yes
8. Do you take aspirin, panadeine or other pain killers? No Yes
9. Do you take any other types of drugs regularly? No Yes
10. Are you often in contact with organic chemicals? (i.e. insecticides, herbicides, petro chemicals etc) No Yes
11. Do you react to strong perfumes, car exhaust, etc? No Yes
12. Do you or have you ever smoked or used tobacco products? No Yes
13.Are you exposed to passive cigarette smoke? No Yes
14. Do you consume beverages/food containing caffeine? No Yes

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LIVER DETOXIFICATION TEST (LDT) SCREENING QUESTIONS

A certain percentage of patients will experience adverse reactions during the LDT. These reactions include, but are not limited to: shakiness, headaches, nausea, palpitations, light-headedness and sweating. The following question will help isolate those patients who may experience these types of reactions.

A. Do you react when you consume caffeine-containing beverages or food?
B. Are you sensitive to food additives such as M.S.G.?
No
Yes
C. Do you have a history of liver problems? If yes please describe the type of the problem below:
No
Yes
Are you currently taking any drugs? If yes please list below: No Yes
What are your healthgoals:
Are you currently taking the supplements prescribed by Hands On? If yes please list below: No Yes
Are you doing the exercises given to you by Hands On? No Yes