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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
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ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com

The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Metabolic Appraisal Questionnaire
PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:

Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com
Copyright 1999 Donna F. Smith

INSTRUCTIONS
     Using the Point Scale below, mark the appropriate number which describes the symptoms or areas of the body in which you are experiencing or have experienced symptoms.
     For diagnoses, mark the number only if you have received the diagnosis from a healthcare provider (MD, DC, ND, etc.)
     Regarding nutritional questions, such as "Poor Protein Assimilation," answer only if these were indicated on a clinical nutrition analysis from a Licensed or Certified Nutritionist or other healthcare provider.
     Answer every question that applies to you, even if a symptom, diagnosis or area of the body appears more than once.

POINT SCALE:
0 = Not Applicable
1 = Past
3 = Occasionally
5 = Current
Section A-1
1. Poor Coordination 0 1 3 5
2. Over-acid stomach 0 1 3 5
3. Indigestion 0 1 3 5
4. Heartburn 0 1 3 5
5. Gas 0 1 3 5
6. Stomach pain 0 1 3 5
7. Stomach spasms 0 1 3 5
8 Protruding Stomach 0 1 3 5
9. Intestinal pain 0 1 3 5
10. Intestinal spasms 0 1 3 5
11. Small intestines 0 1 3 5
12. Periods of extreme mood swings
 0 1 3 5
13. Pancreas 0 1 3 5
14. Constipation 0 1 3 5
15. Hemorrhoids 0 1 3 5
16. Gastric Ulcers 0 1 3 5
17. Gout 0 1 3 5
18. Bone and Joint Pain 0 1 3 5
19. Colon Irregularities 0 1 3 5
20. Gastritis 0 1 3 5
21. Bloating 0 1 3 5
22. Malaise and Fatigue after lunch 0 1 3 5
23. Periods of Poor Concentration 0 1 3 5

Subtotal for Section A-1
Section A-2
24. Poor Protein Assimilation 0 1 3 5
25. Colitis 0 1 3 5
26. Diverticulitis 0 1 3 5
27. Regional Enteritis 0 1 3 5
28. Colon Pathologies, other than colitis, diverticulitis, regional enteritis: 0 1 3 5
29. Gastro-intestinal Tract Disease 0 1 3 5
30. Small Intestines Disease 0 1 3 5
31. Pancreatic Disease 0 1 3 5
32. Excessive Cholesterol Production 0 1 3 5

Subtotal for Section A-2
Grand Total - Section A
Section B-1
1. Poor carbohydrate utilization 0 1 3 5
2. Refined carbohydrate 0 1 3 5
3. Overweight 0 1 3 5
4. Weight control is a major problem 0 1 3 5
5. Water Retention 0 1 3 5
6. Bowel Irregularities 0 1 3 5
7. Poor Skin tone 0 1 3 5
8. Occasional Itching 0 1 3 5
9. Headaches 0 1 3 5
10. Anxiety 0 1 3 5
11. Nervous tension 0 1 3 5
12. Vertigo 0 1 3 5
13. Disorientation 0 1 3 5
14. Occasional Memory Lapse 0 1 3 5
15. Lower Back Pain 0 1 3 5
16. Leg Pain 0 1 3 5

Total for Section B-1
Section B-2
17. Diabetes 0 1 3 5
18. Pre-diabetic 0 1 3 5
19. Dysinsulinism tendencies 0 1 3 5
20. Adverse reactions to sugar and starches 0 1 3 5
21. Have you ever had 6-Hour glucose tolerance test? 0 1 3 5
22. Swelling of the joints 0 1 3 5
23. Poor Vision 0 1 3 5
24. Mood Swings 0 1 3 5

Total for Section B-2
 Grand Total - Section B
Section C-1
1. Periodic moments of elation followed by times of extreme fatigue 0 1 3 5
2. Dietary inconsistencies such as excessive food intake followed by dietary restrictions 0 1 3 5
3. Cycles of diarrhea and constipation 0 1 3 5
4. A feeling of pressure in ears 0 1 3 5
5. Poor protein digestion 0 1 3 5
6. Poor Gall bladder integrity - stones, pain, inability to digest fats/oils 0 1 3 5
7. Bouts with sugar cravings 0 1 3 5
8. Bowel Gas 0 1 3 5

Subtotal for Section C-1
Section C-2
9. Excessive food intake 0 1 3 5
10. Lack of fluid consumption 0 1 3 5
11. Excessive metabolic waste production 0 1 3 5
12. Headaches 0 1 3 5
13. Constipation 0 1 3 5
14. Malabsorption syndrome 0 1 3 5
15. Diarrhea 0 1 3 5

Subtotal for Section C-2
Grand Total for Section C
Section D-1
1. Overweight 0 1 3 5
2. Poor mineral assimilation 0 1 3 5
3. More than average sleep required 0 1 3 5
4. Predisposed to colds 0 1 3 5
5. Predisposed to flu viruses 0 1 3 5
6. Sinus problems 0 1 3 5
7. Allergic reactions 0 1 3 5
8. Cold feet 0 1 3 5
9. Cold hands 0 1 3 5
10. Indigestion 0 1 3 5
11. Easily Fatigued 0 1 3 5

Subtotal for Section D-1
Section D-2
12. Slow metabolism 0 1 3 5
13. Low Energy or fatigue 0 1 3 5
14. Adrenals 0 1 3 5
15. Thyroid 0 1 3 5
16. Chronic Condition of the 0 1 3 5
17. Vertigo 0 1 3 5
18. Pituitary 0 1 3 5

Subtotal for Section D-2
Grand Total for Section D
Section E-1
1. Nervous Tension 0 1 3 5
2. Anxiety 0 1 3 5
3. Hyperactivity 0 1 3 5
4. High Cholesterol 0 1 3 5
5. Irregular blood pressure 0 1 3 5
6. Headaches 0 1 3 5
7. Easily Annoyed 0 1 3 5
8. Easily Distracted 0 1 3 5
9. Sense of hunger even after meals 0 1 3 5
10. Depression 0 1 3 5
11. Water Retention 0 1 3 5
12. Pulse rate easily accelerated above normal 0 1 3 5
13. Shortness of breath 0 1 3 5

Subtotal for Section E-1

Section E-2
1. Bone and Joint Disease 0 1 3 5
2. Nerve transmission syndromes 0 1 3 5
3. Muscle spasms 0 1 3 5
4. High blood pressure 0 1 3 5
5. Low blood pressure 0 1 3 5
6. Diarrhea 0 1 3 5
7. Renal tubular damage 0 1 3 5
8. Acidosis 0 1 3 5
9. Adrenocortical insufficiency 0 1 3 5
10. Take Diuretics 0 1 3 5
11. Lack of tissue salts 0 1 3 5
12. Cramps 0 1 3 5
13. Aches 0 1 3 5
14. General pain 0 1 3 5
15. Nervousness 0 1 3 5
16. Hyperactivity 0 1 3 5
17. Sleeplessness 0 1 3 5
18. Arthritis 0 1 3 5
19. Severe burns 0 1 3 5

If you are currently taking Diuretics, provide the Dosage     
Frequency:(# of times) Daily      Weekly      Monthly
Subtotal for Section E-2
Grand Total for Section E
Section F-1
1. Drowsiness 0 1 3 5
2. Weight control problems 0 1 3 5
3. Excessive water retention 0 1 3 5
4. Lack of stamina 0 1 3 5
5. Hypertensive 0 1 3 5
6. Temperature sensitive 0 1 3 5
7. Moods change with weather 0 1 3 5
8. Headaches 0 1 3 5
9. Ringing in Ears 0 1 3 5
10. Oily Skin 0 1 3 5
11. Halitosis (bad breath) 0 1 3 5
12. Nervousness 0 1 3 5

Subtotal for Section F-1
Section F-2
1. Liver problems 0 1 3 5
2. Gall bladder problems 0 1 3 5
3. Poor digestion 0 1 3 5
4. Dry Skin 0 1 3 5
5. Cold flashes 0 1 3 5
6. Hot flashes 0 1 3 5
7. Edema 0 1 3 5
8. Hypertension 0 1 3 5
9. Taking metabolic altering medication(s) 0 1 3 5
10. Hyperaldosteronism 0 1 3 5
11. Cushings syndrome 0 1 3 5
12. Cerebral damage 0 1 3 5
13. Disturbances of consciousness 0 1 3 5

Subtotal for Section F-2
Grand Total for Section F
Section G-1
1. Premature aging 0 1 3 5
2. Hair loss 0 1 3 5
3. Elevated levels of toxicity 0 1 3 5
4. Bowel toxicity 0 1 3 5
5. Highly sensitive to lactate and starchy foods 0 1 3 5
6. Types of Foods Crave: 0 1 3 5
7. Poor Circulation 0 1 3 5
8. Aches in Joints 0 1 3 5
9. Sleeping Difficulties 0 1 3 5
10. Acid Stomach 0 1 3 5

Total for Section G-1
Section G-2
11. Indigestion 0 1 3 5