Ntaf.pdf

Metabolic Assessment Form
Name: ___________________________________________ Age: ______ Sex: _____ Date: ______________
Please list the 5 major health concerns in your order of importance:
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
5. __________________________________________________________________________________________
Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.
Category I
Category V
Feeling that bowels do not empty completely . . . . . . 0 1 2 3
Greasy or high-fat foods cause distress . . . . . . . . . . . 0 1 2 3
Lower abdominal pain relief by passing stool or gas . 0 1 2 3
Alternating constipation and diarrhea . . . . . . . . . . . . . 0 1 2 3
several hours after eating . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
especially in the morning . . . . . . . . . . . . . . . . . . . 0 1 2 3
Hard, dry, or small stool . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Unexplained itchy skin . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Coated tongue of “fuzzy” debris on tongue . . . . . . . . . 0 1 2 3
Yellowish cast to eyes . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Pass large amount of foul smelling gas . . . . . . . . . . . . 0 1 2 3
Stool color alternates from clay colored More than 3 bowel movements daily . . . . . . . . . . . . . . 0 1 2 3
to normal brown . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Use laxatives frequently . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Reddened skin, especially palms . . . . . . . . . . . . . . . . 0 1 2 3
Dry or fl aky skin and/or hair . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category II
History of gallbladder attacks or stones . . . . . . . . . . . 0 1 2 3
Excessive belching, burping, or bloating . . . . . . . . . . . 0 1 2 3
Have you had your gallbladder removed . . . . . . . . . . . .
Gas immediately following a meal . . . . . . . . . . . . . . . 0 1 2 3
Offensive breath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Category VI
Diffi cult bowel movements . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Crave sweets during the day . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Sense of fullness during and after meals . . . . . . . . . . . 0 1 2 3
Irritable if meals are missed . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Diffi culty digesting fruits and vegetables; Depend on coffee to keep yourself going or started . . 0 1 2 3
undigested foods found in stools . . . . . . . . . . . . . . . 0 1 2 3
Get lightheaded if meals are missed . . . . . . . . . . . . . . 0 1 2 3
Eating relieves fatigue . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category III
Feel shaky, jittery, or have tremors . . . . . . . . . . . . . . . 0 1 2 3
Agitated, easily upset, nervous . . . . . . . . . . . . . . . . . 0 1 2 3
hours after eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Poor memory/forgetful . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Use antacids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Blurred vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Feel hungry an hour or two after eating . . . . . . . . . . . 0 1 2 3
Heartburn when lying down or bending forward . . . . 0 1 2 3
Category VII
Fatigue after meals . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
milk, carbonated beverages . . . . . . . . . . . . . . . . . . . 0 1 2 3
Crave sweets during the day . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Digestive problems subside with rest and relaxation . 0 1 2 3
Eating sweets does not relieve cravings for sugar . . . 0 1 2 3
Heartburn due to spicy foods, chocolate, citrus, Must have sweets after meals . . . . . . . . . . . . . . . . . . . 0 1 2 3
peppers, alcohol, and caffeine . . . . . . . . . . . . . . . . . 0 1 2 3
Waist girth is equal or larger than hip girth . . . . . . . . 0 1 2 3
Frequent urination . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category IV
Increased thirst and appetite . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Roughage and fi ber cause constipation . . . . . . . . . . . . 0 1 2 3
Diffi culty losing weight . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
hours after eating . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category VIII
Cannot stay asleep . . . . . . . . . . . . . . . . . . . . . . . . . . . under rib cage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Crave salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Excessive passage of gas . . . . . . . . . . . . . . . . . . . . . . . Slow starter in the morning . . . . . . . . . . . . . . . . . . . .
Nausea and/or vomiting . . . . . . . . . . . . . . . . . . . . . . . Afternoon fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dizziness when standing up quickly . . . . . . . . . . . . . . mucous-like, greasy, or poorly formed . . . . . . . . . Afternoon headaches . . . . . . . . . . . . . . . . . . . . . . . . . . Frequent urination . . . . . . . . . . . . . . . . . . . . . . . . . . . . Headaches with exertion or stress . . . . . . . . . . . . . . . .
Increased thirst and appetite . . . . . . . . . . . . . . . . . . . . Weak nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diffi culty losing weight . . . . . . . . . . . . . . . . . . . . . . . Symptom groups listed in this fl yer are not intended to be used as a diagnosis of any disease condition. All Rights Reserved. Copyright 2009, Datis Kharrazian
SMGEMAF04(1009)-INHOUSE.INDD
Category IX
Category XIV (Males only)
Cannot fall asleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Urination diffi culty or dribbling . . . . . . . . . . . . . . . . . 0 1 2 3
Perspire easily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Frequent urination . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Under high amounts of stress . . . . . . . . . . . . . . . . . . . 0 1 2 3
Pain inside of legs or heels . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Weight gain when under stress . . . . . . . . . . . . . . . . . . 0 1 2 3
Feeling of incomplete bowel evacuation . . . . . . . . . . 0 1 2 3
Wake up tired even after 6 or more hours of sleep . . . 0 1 2 3
Leg nervousness at night . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Excessive perspiration or perspiration with little or no activity . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category XV (Males only)
Decrease in libido . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category X
Decrease in spontaneous morning erections . . . . . . . . 0 1 2 3
Tired, sluggish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Decrease in fullness of erections . . . . . . . . . . . . . . . . 0 1 2 3
Feel cold – hands, feet, all over . . . . . . . . . . . . . . . . . . 0 1 2 3
Diffi culty in maintaining morning erections . . . . . . . . . . Spells of mental fatigue . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
function properly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inability to concentrate . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Increase in weight gain even with low-calorie diet . . . 0 1 2 3
Episodes of depression . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Gain weight easily . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Muscle soreness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Diffi cult, infrequent bowel movements . . . . . . . . . . . . 0 1 2 3
Decrease in physical stamina . . . . . . . . . . . . . . . . . . . 0 1 2 3
Depression, lack of motivation . . . . . . . . . . . . . . . . . . 0 1 2 3
Unexplained weight gain . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Increase in fat distribution around chest and hips . . . 0 1 2 3
as the day progresses . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Sweating attacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Outer third of eyebrow thins . . . . . . . . . . . . . . . . . . . . 0 1 2 3
More emotional than in the past . . . . . . . . . . . . . . . . . 0 1 2 3
Thinning of hair on scalp, face, or genitals or Category XVI (Menstruating Females Only)
excessive falling hair . . . . . . . . . . . . . . . . . . . . . . . . Are you perimenopausal . . . . . . . . . . . . . . . . . . . . . . . . . Dryness of skin and/or scalp . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Alternating menstrual cycle lengths . . . . . . . . . . . . . . . . Mental sluggishness . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Extended menstrual cycle, greater than 32 days . . . . . . Shortened menses, less than every 24 days . . . . . . . . . . Category XI
Pain and cramping during periods . . . . . . . . . . . . . . . Heart palpitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Scanty blood fl ow . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inward trembling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Heavy blood fl ow . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increased pulse even at rest . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Breast pain and swelling during menses . . . . . . . . . . Nervous and emotional . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Pelvic pain during menses . . . . . . . . . . . . . . . . . . . . . Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Irritable and depressed during menses . . . . . . . . . . . . Night sweats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Acne breakouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diffi culty gaining weight . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Facial hair growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Hair loss/thinning . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Category XII
Diminished sex drive . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category XVII (Menopausal Females Only)
Menstrual disorders or lack of menstruation . . . . . . . . 0 1 2 3
How many years have you been menopausal? ____________
Increased ability to eat sugars without symptoms . . . . 0 1 2 3
Since menopause, do you ever have uterine bleeding? Yes No
Hot fl ashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Category XIII
Mental fogginess . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Increased sex drive . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Disinterest in sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Tolerance to sugars reduced . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Mood swings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
“Splitting” type headaches . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Painful intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Shrinking breasts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Facial hair growth . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1 2 3
Increased vaginal pain, dryness or itching . . . . . . . . 0 1 2 3
How many alcoholic beverages do you consume per week? ________ How many caffeinated beverages do you consume per day? _________ How many times do you eat out per week? ___________ How many times a week do you eat raw nuts or seeds? _____________ How many times a week do you eat fi sh? ___________ How many times a week do you workout? _______________________List the three worst foods you eat during the average week: _____________________, ______________________, _____________________ List the three healthiest foods you eat during the average week: _____________________, _____________________, __________________ Do you smoke?_______ If yes, how many times a day: ____________ Rate your stress levels on a scale of 1-10 during the average week: __________________ Please list any medications you currently take and for what conditions:
____________________________________________________________________________________________________________________
Please list any natural supplements you currently take and for what conditions:
____________________________________________________________________________________________________________________
All Rights Reserved. Copyright 2009, Datis Kharrazian
SMGEMAF04(1009)-INHOUSE.INDD
Health Questionnaire (NTAF)
Name: _____________________________________Age: ______ Sex: ________ Date:
* Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.
SECTION A
• Is your memory noticeably declining?
• How often do you feel you lack artistic appreciation? • Are you having a hard time remembering names • How often do you feel depressed in overcast weather? • How much are you losing your enthusiasm for your • Is your ability to focus noticeably declining? • Has it become harder for you to learn things? • How much are you losing enjoyment for • How often do you have a hard time remembering • How much are you losing your enjoyment of • Is your temperament getting worse in general? 0 1 2 3 friendships and relationships?
• Are you losing your attention span endurance? • How often do you have dif¿ culty falling into • How often do you ¿ nd yourself down or sad? • How often do you fatigue when driving compared • How often do you have feelings of dependency • How often do you fatigue when reading compared • How often do you feel more susceptible to pain? • How often do you have feelings of unprovoked anger? • How often do you walk into rooms and forget why? • How much are you losing interest in life? • How often do you pick up your cell phone and forget why? SECTION 2 - D
SECTION B
• How often do you have feelings of hopelessness? • How often do you have self-destructive thoughts? • How often do you feel that you have something that • How often do you have an inability to handle stress? • How often do you have anger and aggression while • Do you feel you never have time for yourself? • How often do you feel you are not getting enough • How often do you feel you are not rested even after • Do you ¿ nd it dif¿ cult to get regular exercise? • How often do you prefer to isolate yourself from others? • Do you feel uncared for by the people in your life? • How often do you have unexplained lack of concern for • Do you feel you are not accomplishing your • How easily are you distracted from your tasks? • Is sharing your problems with someone dif¿ cult for you? 0 1 2 3
• How often do you have an inability to ¿ nish tasks? • How often do you feel the need to consume caffeine to SECTION C
• How often do you feel your libido has been decreased? • How often do you lose your temper for minor reasons? • How often do you get irritable, shaky, or have • How often do you have feelings of worthlessness? • How often do you feel energized after eating? SECTION 3 - G
• How often do you have dif¿ culty eating large • How often do you feel anxious or panic for no reason? • How often do you have feelings of dread or • How often does your energy level drop in the afternoon? • How often do you crave sugar and sweets in the afternoon? • How often do you feel knots in your stomach? • How often do you wake up in the middle of the night? • How often do you have feelings of being overwhelmed • How often do you have dif¿ culty concentrating • How often do you have feelings of guilt about • How often do you depend on coffee to keep yourself going? • How often do you feel agitated, easily upset, and nervous • How often does your mind feel restless? • How dif¿ cult is it to turn your mind off when you want to relax? • How often do you have disorganized attention? • How often do you worry about things you were • Do you crave sugar and sweets after meals? • Do you feel you need stimulants such as coffee after meals? • How often do you have feelings of inner tension and • Do you have dif¿ culty losing weight? • How much larger is your waist girth compared to your hip girth? SECTION 4 - ACH
• Do you feel your visual memory (shapes & images) • Have your thirst and appetite been increased? • Do you have weight gain when under stress? • Do you feel your verbal memory is decreased? • Do you have dif¿ culty falling asleep? 0 1 2 3
SECTION 1 - S
• Has your comprehension been diminished? • Are you losing your pleasure in hobbies and interests? • Do you have dif¿ culty calculating numbers? • How often do you feel overwhelmed with ideas to manage? • Do you have dif¿ culty recognizing objects & faces? • How often do you have feelings of inner rage (anger)? • Do you feel like your opinion about yourself • How often do you have feelings of paranoia? • How often do you feel sad or down for no reason? • Are you experiencing excessive urination? • How often do you feel like you are not enjoying life? • Are you experiencing slower mental response? Symptom groups listed in this À yer are not intended to be used as a diagnosis of any disease condition.
All Rights Reserved. Copyright 2009, Datis Kharrazian SMGEPQNTAF04(1209).INDD
Medication History*
Please circle any of the following medication you have been or are currently taking.
Acetylcholine Receptor Antagonist – Antimuscarinic Agents
Atropine, Ipratopium, Scopolamine, Tiotropium
Acetylcholine Receptor Antagonist - Ganlionic Blockers
Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan
Acetylcholinesterase Reactivators
Pralidoxime
Acetylcholine Receptor Antagonist - Neuromuscular Blockers
Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Succinylcholine, Tubocurarine,
Vecuronium, Hemicholinium
Agonist Modulator of GABA Receptor (benzodiazpines)
Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSom, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum,
Megadon, Serax, Restoril, Halcion
Agonist Modulator of GABA Receptors (nonbenzodiazpines)
Ambien, Sonata, Lunesta, Imovane
Cholinesterase Inhibitors (irreversible)
Echotiophate, IsoÀ urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents
Cholinesterase Inhibitors (reversible)
Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Edrophonium, Neostigmine, Physostigmine, Pyridostigmine,
Carbamate Insecticidses
Dopamine Reuptake Inhibitors
Wellbutrin (Bupropion)
Dopamine Receptor Agonists
Mirapex, Sifrol, Requip
D2 Dopamine Receptor Blockers (antipsychotics)
Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, Fluanxol, Clopixol,
Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify
GABA Antagonist Competitive binder
Flumazenil
Monoamine Oxidase Inhibitors (MAOI)
Marplan, Aurorix, Manerix, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid
Noradrenergic and Speci¿ c Sertonergic Antidepressants (NaSSaa)
Remeron, Zispin, Avanza, Norset, Remergil, Axit
Selective Serotonin Reuptake Inhibitors
Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil, Emocal, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil,
Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Paroxat, Lustral, Serlain, Dapoxetine
Selective Serotonin Reuptake Enhancers
Stablon, Coaxil, Tatinol
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despiramin, Duloxetine
Tricylic Antidepressants (TCAs)
Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiaden,
Adapin, Sinequan, Tofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil
*Please refer to prescribing physician for nutritional interactions with any medications you may be taking.
All Rights Reserved. Copyright 2009, Datis Kharrazian

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