Please enable JavaScript in your browser to complete this form.Metabolic Stress Questionnaire Rate each of the following symptoms based on your typical health profile over the last month. 0 - Never or almost never have the symptoms 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 Name (first and last) *Date *HEAD Headaches *01234Faintness *01234Dizziness *01234Insomnia *01234Notes/comments on this sectionEYES Watery or itchy eyes *01234Swollen, reddened or sticky eyelids *01234Bags or dark circles under the eyes *01234Blurred or tunnel vision *01234Notes/comments on this sectionEARS Itchy ears *01234Earaches, ear infections *01234Drainage from ear *01234Ringing in ear, tinnitus, hearing loss *01234Notes/comments on this sectionNOSE Stuffy nose *01234Sinus problems *01234Hay fever *01234Sneezing attacks *01234Excessive mucus formation *01234Notes/comments on this sectionMOUTH/THROAT Chronic coughing *01234Gagging, frequent need to clear throat *01234Sore throat, hoarseness, loss of voice *01234Swollen or discolored tongue, gums, lips *01234Canker sores *01234Notes/comments on this sectionSKIN Acne *01234Hives, rashes, dry skin *01234Hair loss *01234Flushing, hot flashes *01234Excessive sweating *01234Notes/comments on this sectionHEART Chest pain *01234Irregular or skipped heartbeat *01234Rapid or pounding heartbeat *01234Notes/comments on this sectionLUNGS Chest congestion *01234Asthma, bronchitis *01234Shortness of breath *01234Difficulty breathing *01234Notes/comments on this sectionDIGESTIVE TRACT Nausea, vomiting *01234Diarrhea *01234Constipation *01234Bloated feeling *01234Belching, passing gas *01234Heartburn *01234Intestinal/stomach pain *01234Notes/comments on this sectionJOINTS/MUSCLE Pain or aches in joints *01234Arthritis *01234Stiffness or limitation of movement *01234Feeling of weakness or tiredness *01234Pain or aches in muscles *01234Notes/comments on this sectionWEIGHT Binge eating/drinking *01234Craving certain foods *01234Excessive weight *01234Water retention *01234Underweight *01234Compulsive eating *01234Notes/comments on this sectionENERGY/ACTIVITY Fatigue, sluggishness *01234Apathy, lethargy *01234Hyperactivity *01234Restlessness *01234Notes/comments on this sectionMIND section weight nervousness Poor memory *01234Confusion, poor comprehension *01234Difficulty in making decisions *01234Stuttering or stammering *01234Slurred speech *01234Learning disabilities *01234Poor concentration *01234Poor physical coordination *01234Notes/comments on this sectionEMOTIONS Mood swings *01234Anxiety, fear, nervousness *01234Anger, irritability, aggression *01234Depression *01234Notes/comments on this sectionOTHER Frequent illness *01234Frequent or urgent urination (unrelated to high water intake) *01234Genital itch or discharge *01234Notes/comments on this sectionADDITIONAL QUESTIONS Are you presently using prescription drugs? *Yes (1)No (0)(numbers in parentheses are used for scoring, please ignore)If yes to the above, how many are you taking?Are you presently taking any of these OTC drugs? *Cimetidine (Tagamet, Acid Reducer) (2)Acetaminophen (Tylenol) (2)Estradiol (2)None of these (0)If you have or are using Rx drugs, what best described your response? *Experienced side effects, still effective at lowered dose (3)Experienced side effects, effective at normal dose (2)No side effects, drugs not typically effective (2)No side effects, drugs are typically effective (0)Insufficient experience (0)Are you or have you in the past 6 months regularly used tobacco products? *Yes (2)No (0)Do you find yourself highly sensitive to caffeine? *Yes (1)No (0)Don't know (0)Do you commonly experience "brain fog", fatigue, or drowsiness? *Yes (1)No (0)Do you experience symptoms when exposed to fragrances, exhaust fumes, or strong odors? *Yes (1)No (0)Don't know (0)Do you feel ill after you consume even small amounts of alcohol? *Yes (1)No (0)Don't know (0)Do you have a personal history of... *Environmental and/or chemical sensitivities (5)Chronic fatigue syndrome (5)Multiple chemical sensitivity (5)Fibromyalgia (3)Parkinson's type symptoms (3)Alcohol or chemical dependence (2)Asthma (1)None of these (0)Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents? *Yes (1)No (0)Do you have an adverse or allergic reaction when you consume sulfite-containing foods such as wine, dried fruit, salad bar vegetables, etc? *Yes (1)No (0)Don't know (0)Do you have a history of or currently have kidney dysfunction? *YesNoAre you currently on diuretics or blood pressure medication? *YesNoHave you ever been diagnosed with hyperkalemia (high potassium)? *YesNoSubmit
