Metabolic Fitness Symptom Assessment

Answer the following questions based on the past 30 days on a scale of:
“0” (least/never/zero symptoms)
“1” (minor, mild, rarely, monthly)
“2” (moderate, occasionally, weekly)
“3” (most severe, frequently, daily).

If you haven't had a symptom in the previous 30 days, yet it's been with you the majority of your life, answer "3". Take your time and be candid with your answers; the more accurate, the better we will understand which systems are a priority for you and your body.

*These answers will be kept private, and will not be shared with anyone else, unless you authorize or request it.
Name*
Date of Birth - MM/DD/YY*
Email
How did you hear about Enroot Wellness?
Section 1
Crave sweets and/or carbohydrates*
Crave Sweets after meals*
Frequent thirst*
Feel tired after meals*
Blurred vision*
Section 2
Shaky and irritable between meals*
Eating energizes me and/or relieves fatigue*
Often wake up during the night*
Fatigue, fuzzy thinking, headaches between meals*
Anxiety and palpitations*
Section 3
Difficult time getting going in the morning*
Difficulty falling asleep, a “night person”*
Feel “tired and wired”*
Perspire easily, even with minimal activity*
Elevated blood pressure*
Section 4
Crave salt or liberally salt food*
Lightheaded when standing up quickly*
Difficulty staying asleep*
Low blood pressure*
Fatigue and/or depression*
Section 5
Bloating shortly after a meal*
Experience heartburn, or use antacids*
Excessive belching or burping*
Sensitive to a number of foods*
Indigestion or nausea after eating*
Section 6
Excessive and/or foul-smelling gas*
Lower abdominal bloating relieved by gas*
Constipation*
Diarrhea*
History of antibiotic use*
History of laxative use*
Section 7
Nausea or diarrhea from high-fat foods*
“Greasy” stool that tends to float*
Sensitive to caffeine, alcohol, and/or other synthetic chemicals*
General itchiness, or itchy palms*
Gall bladder removed:*
Section 8
Tendency to be cold, especially hands and feet*
Difficulty losing weight*
Low energy, or tired all the time*
Brain fog, mental sluggishness*
Dry skin, brittle nails, hair loss*
Section 9 (Males)
Decreased libido (sexual drive)
Decrease in morning erections or strength in Erections
Decreased enjoyment in life
Decreased strength and/or endurance
Difficulty building or maintain muscle
Section 10 (Females - Menstruating)
Acne and/or unwanted facial hair growth
Abnormal menstruation (heavy, extended, shortened, scanty)
Pain, cramping, and/or breast tenderness during menses
Significant mood changes during menses
Currently taking, or history of taking, birth control
Section 11 (Females – Menopausal)
Experience hot flashes
Acne and/or unwanted facial hair growth
Mood swings, depression, night sweats
Vaginal thinning, dryness, or itchiness
Low libido (sexual drive)
Section 12
Bleeding gums or nosebleeds, or easily bruised*
Muscle fatigue or excessive soreness after exercise*
Tingling in hands or feet, and/or cracks in the corners of the mouth*
Restless legs and/or muscle cramping/twitching*
Dry/scaly skin and/or bumps on the back of the arms*
Section 13
Feel tired, fatigued, or weak*
Experience shortness of breath*
Coldness in hands and feet, or “poor circulation”*
Experience a rapid, or irregular, heart beat*
Dizziness or lightheadedness*
Section 14
Lack of motivation*
Feelings of worthlessness, or self-destructive thoughts*
Quick to anger or frustration*
Inattentive, poor circulation, disorganized thinking*
Decreased pleasure in life*
Section 15
Loss of enjoyment in favorite activities, or relationships*
Feelings of depression and sadness*
Gut distress and/or decreased pain tolerance*
Feelings of overwhelm, or obsessive thoughts*
Lack of deep, restful sleep*
Section 16
Feelings of anxiety, panic or inner tension*
Experience restlessness, mentally or physically*
Easily worried*
Feel easily overwhelmed and overworked*
Insomnia or difficulty staying asleep*
Section 17
Sensitive to the smell of gasoline, paint, cleaning products, perfumes, or other fragrances*
I live, or work near, heavy traffic, industrial plants farms, electricity, or cellphone towers*
Chronic airways issues including nasal congestion, mucous production, or throat or nasal irritation*
Chronic headaches, muscle or joint stiffness or pain, or skin issues*
Exposure to chemicals, i.e. synthetic fabrics, tap water, cosmetics, cleaning products, and processed food*
Section 18
feel as if nobody understands me*
It is difficult for me to make friends*
People are around me, but not with me*
My social relationships are superficial*
No one really knows me well*
Section 19
I feel in control of my life*
Life is rewarding, I am optimistic about the future*
I am satisfied with my life*
I feel healthy, attractive, and am pleased with who I am*
I find beauty and joy in things, and laugh often*
Section 20
I can easily and succinctly articulate my purpose in life*
I have discovered who I really am*
I get intensely involved in, and feel greatly fulfilled, by many of the things I do each day*
My life is centered around a set of core beliefs that give meaning to life*
It is more important that I enjoy what I do rather than if people are impressed by it*
Number
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Name
This field is for validation purposes and should be left unchanged.

Metabolic Fitness Symptom Assessment

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Section 8

Section 9 (Males)

Section 10 (Females - Menstruating)

Section 11 (Females – Menopausal)

Section 12

Section 13

Section 14

Section 15

Section 16

Section 17

Section 18

Section 19

Section 20

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