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FREE ONLINE METABOLIC ASSESSMENT FORM

IF YOU OR YOUR LOVED ONES LIVE OUTSIDE THE SOUTH FLORIDA AREA AND DESIRE AN OBJECTIVE NUTRITIONAL CONSULTATION WITH EVALUATION THEN PLEASE FOLLOW ALL DIRECTIONS BELOW. PLEASE FILL OUT THE FORMS BELOW AS BEST AS YOU CAN AND CLICK THE SUBMIT BUTTON ON THE BOTTOM.

AFTER ALL MATERIALS ARE RECEIVED, DR. GUBERMAN WILL REVIEW ALL INFORMATION.

DR. GUBERMAN WANTS YOU TO KNOW THAT HE WILL DO EVERYTHING POSSIBLE TO ASSURE YOU THE BEST NUTRITIONAL PROGRAM THAT IS FOCUSED ON YOUR AREAS OF NEED TO BRING YOU BACK TO OPTIMUM HEALTH.

PLEASE FILL OUT THE FOLLOWING FORM ( * Denotes Required Field):

Date:

Your Name*: DATE OF BIRTH:
Address:
City: State:
Zip Code:
Email*:
Home Phone*: Work Phone:
Select if you are:
Name of Husband or Wife: Ages of Children:
Where are you and husband/wife employed:
PART 1: MAJOR COMPLAINTS
  

PLEASE DESCRIBE YOUR MAJOR PROBLEMS IN ORDER OF THERE SEVERITY. PLEASE SUPPORT THESE COMPLAINTS WITH AS MUCH OBJECTIVE TESTINGS AS POSSIBLE:

This field is required for Dr. guberman to be able to begin his review and consulation. Please take time
to tell us as much as you can about your condiition so that Dr. Guberman can begin an accurate
assessment of your personal situation.
PART 2: SYMPTOMS
  

Please select the appropriate number “0 - 3” on all questions below.
0 as the least/never to 3 as the most/always.

CATEGORY I
0
1
2
3
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 of “fuzzy” debris on tongue
Pass large amount of foul smelling gas
More than 3 bowel movements daily
Do you use laxatives frequently

 

CATEGORY II
0
1
2
3
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
0
1
2
3
Stomach pain, burning or aching 1- 4 hours after eating
Do you frequently use antacids
Feeling 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

 

CATEGORY IV
0
1
2
3
Roughage and fiber cause constipation
Indigestion and fullness lasts 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling, mucous-like, greasy or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty losing weight

 

CATEGORY V
0
1
2
3
Greasy or high fat foods cause distress
Lower bowel gas and or bloating several hours after eating
Bitter metallic taste in mouth, especially in the morning
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed (0 = No, 1 = Yes)

 

CATEGORY VI
0
1
2
3
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep yourself going or started
Get lightheaded and if meals are missed
Eating relieves fatigue
Feel shaky, jit tery, tremors
Agitated, easily upset, nervous
Poor memory, forgetful
Blurred vision

 

CATEGORY VII
0
1
2
3
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst & appetite
Difficulty losing weight

 

CATEGORY VIII
0
1
2
3
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails

 

CATEGORY IX
0
1
2
3
Cannot fall asleep
Perspire easily
Under high amounts of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little or no activity

 

CATEGORY X
0
1
2
3
Tired, sluggish
Feel cold – hands, feel, all over
Require excessive amounts of sleep to function properly
Increase in weight gain even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression, lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face or genitals or excessive falling hair
Dryness of skin and/or scalp
Mental sluggishness

 

CATEGORY XI
0
1
2
3
Heart palpations
Inward trembling
Increased pulse even at rest
Nervousness and emotional
Insomnia
Night sweats
Difficulty gaining weight

 

CATEGORY XII
0
1
2
3
Diminished sex drive
Menstrual disorders of lack of menstruation
Increased ability to eat sugars without symptoms

 

CATEGORY XIII
0
1
2
3
Increased sex drive
Tolerance to sugars reduced
“Splitting” type headaches

 

CATEGORY XIV (Males Only)
0
1
2
3
Urination difficulty or dribbling
Urination frequent
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night

 

CATEGORY XV (Males Only)
0
1
2
3
Decrease in libido
Decrease in spontaneo us morning erections
Decrease in fullness of erections
Difficulty in maintain morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decrease in physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional then in the past