Patient Metabolic Form

Metabolic Assessment Form

For Current Patients Undergoing Functional Medicine Treatment

Assessment Form

Complete the following form to the best of your ability and submit it to our office. We will use these forms to help in your overall healthcare assessment for better diagnosis and treatment of your issues.

Metabolic Assessment Form

Step 1 of 5


6035 Shallowford Rd Suite 101
Chattanooga, TN 37421
OFFICE 423-499-0003 | FAX 423-485-7992


Name(Required)
MM slash DD slash YYYY
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Please list the 5 major health concerns in your order of importance.

Category I

Please check the appropriate number "0-3" on all questions below. 0 as the least/never to 3 as the most/always.
Feeling that bowels do not empty completely.
Lower abdominal pain relief by passing stool or gas .
Alternating constipation and diarrhea.
Diarrhea.
Constipation.
Hard, dry, or small stool.
Coated tongue or "fuzzy" debris on tongue.
Pass large amount of foul smelling gas.
More than 3 bowel movements per day.
Use laxatives frequently.

Category II

Excessive belching, burping, or bloating.
Gas immediately following a meal.
Offensive breath
Difficult bowel movements.
Sense of fullness during and after meals.
Difficulty digesting fruits and vegetables; undigested foods found in stools.

Category III

Stomach 'pain, burning, or aching 1- 4 hours after eating.
Use antacids.
Feel hungry an hour or two after eating.
Heartburn when lying down or bending forward.
Temporary relief from antacids, food, milk, carbonated beverages.
Digestive problems subside with rest and relaxation.
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine.

APPOINTMENTS

If you are interested in scheduling a consultation to see if you are a Non-Surgical candidate or are looking to get off your medications, we are here to serve you! Simply complete the quick form on the left to send a message to our team. Our friendly office staff will take your request in the order in which it is received and we will get in touch with you either by email or phone.

EMAIL FOR AN APPOINTMENT
CALL FOR AN APPOINTMENT

If you have been seriously injured and need immediate help, call 911. If you were recently injured but need our services as soon as we can get you in, call our office for an appointment:

CALL FOR AN APPOINTMENT - (423) 499-0003.

(423) 499-0003

6035 Shallowford Rd,
Chattanooga, TN 37421

Hours of Operation:

MON: 8:30am-12:30pm  &  2:00pm-6:00pm
WED: 8:30am-12:30pm  &  2:00pm-6:00pm
THUR: 9:00am-12:30pm &  2:00pm-6:00pm
FRI: 8:30am-12:30pm  &  2:00pm-6:00pm

Contact US:

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