Progress paperwork Name(Required)Email(Required) Date(Required) Please enter the time zone you are in.(Required)Please complete the following evaluation update form so we can better understand your progress and goals.1. Symptom/Concern. How Much has Symptom Improved(Required) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What Symptom One Is?(Required)2. Symptom/Concern. How Much has Symptom Improved(Required) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What Symptom Two Is?(Required)3. Symptom/Concern. How Much has Symptom Improved(Required) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What Symptom Three Is?(Required)4. Symptom/Concern. How Much has Symptom Improved(Required) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What Symptom Four Is?(Required)5. Symptom/Concern. How Much has Symptom Improved(Required) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What Symptom Five Is?(Required)Your current health goals with our office are:(Required)Please list all specific improvements in your life since starting care in our office:(Required)Do you feel the frequency of follow ups with Dr Hagmeyer is sufficient? Yes No If No, please explain:(Required)Do you feel the frequency of follow ups with your Nutritionist is sufficient?(Required) Yes No If No, please explain:(Required)Do you find your Nutritionist helpful?(Required) Yes No If No, please explain:(Required)Do you have any frustrations or new concerns with your progress?(Required)Have you been following and adhering to the Dietary Changes needed in order to heal and repair tissues?(Required) Yes No If No, please explain:(Required)Have you been following and adhering to the Targeted Nutritional Supplements prescribed in order to heal and repair tissues to their maximum ability?(Required) Yes No If No, please explain:(Required)Our office is built on referrals from people like you! Are there any suggestions you have to make our office better?(Required)Do you feel comfortable referring friends and family to our office?(Required) Yes No If Yes, have you had the opportunity?(Required) Yes No Who?(Required)If No, please share why:(Required)Other Comments:(Required) PAGE 2 Metabolic Assessment FormName:(Required)Age:(Required)Sex:(Required)Date:(Required) PART IPlease list your 5 major health concerns in order of importance:1 major health concerns.(Required)2 major health concerns.(Required)3 major health concerns.(Required)4 major health concerns.(Required)5 major health concerns.(Required)PART IIPlease circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.Category I(Required)0123Feeling that bowels do not empty completelyLower abdominal pain relieved by passing stool or gasAlternating constipation and diarrheaDiarrheaConstipationHard, dry, or small stoolCoated tongue or “fuzzy” debris on tonguePass large amount of foul-smelling gasMore than 3 bowel movements dailyUse laxatives frequentlyCategory II(Required)0123Increasing frequency of food reactionsUnpredictable food reactionsAches, pains, and swelling throughout the bodyUnpredictable abdominal swellingFrequent bloating and distention after eatingAbdominal intolerance to sugars and starchesCategory III(Required)0123Intolerance to smellsIntolerance to jewelryIntolerance to shampoo, lotion, detergents, etcMultiple smell and chemical sensitivitiesConstant skin outbreaksCategory IV(Required)0123Excessive belching, burping, or bloatingGas immediately following a mealOffensive breathDifficult bowel movementsSense of fullness during and after mealsDifficulty digesting fruits and vegetables; undigested food found in stoolsCategory V(Required)0123Stomach pain, burning, or aching 1-4 hours after eatingUse of antacidsFeel hungry an hour or two after eatingHeartburn when lying down or bending forwardTemporary relief by using antacids, food, milk, or carbonated beveragesDigestive problems subside with rest and relaxationHeartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeineCategory VI(Required)0123Roughage and fiber cause constipationIndigestion and fullness last 2-4 hours after eatingPain, tenderness, soreness on left side under rib cageExcessive passage of gasNausea and/or vomitingStool undigested, foul smelling, mucus like, greasy, or poorly formedFrequent urinationIncreased thirst and appetiteCategory VII(Required)0123Abdominal distention after consumption of fiber, starches, and sugarAbdominal distention after certain probiotic or natural supplementsLowered gastrointestinal motility, constipationRaised gastrointestinal motility, diarrheaAlternating constipation and diarrheaSuspicion of nutritional malabsorptionFrequent use of antacid medicationHave you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?(Required) Yes No Category VIII(Required)0123Greasy or high-fat foods cause distressLower bowel gas and/or bloating several hours after eatingBitter metallic taste in mouth, especially in the morningBurpy, fishy taste after consuming fish oilsDifficulty losing weightUnexplained itchy skinYellowish cast to eyesStool color alternates from clay colored to normal brownReddened skin, especially palmsDry or flaky skin and/or hairHistory of gallbladder attacks or stonesHave you had your gallbladder removed?(Required) Yes No Category IX(Required)0123Acne and unhealthy skinExcessive hair lossOverall sense of bloatingBodily swelling for no reasonHormone imbalancesWeight gainPoor bowel functionExcessively foul-smelling sweatCategory X(Required)0123Crave sweets during the dayIrritable if meals are missedDepend on coffee to keep going/get startedGet light-headed if meals are missedEating relieves fatigueFeel shaky, jittery, or have tremorsAgitated, easily upset, nervousPoor memory/forgetfulBlurred visionCategory XI(Required)0123Fatigue after mealsCrave sweets during the dayEating sweets does not relieve cravings for sugarMust have sweets after mealsWaist girth is equal or larger than hip girthFrequent urinationIncreased thirst and appetiteDifficulty losing weightCategory XII(Required)0123Cannot stay asleepCrave saltSlow starter in the morningAfternoon fatigueDizziness when standing up quicklyAfternoon headachesHeadaches with exertion or stressWeak nailsCategory XIII(Required)0123Cannot fall asleepPerspire easilyUnder a high amount of stressWeight gain when under stressWake up tired even after 6 or more hours of sleepExcessive perspiration or perspiration with little or no activityCategory XIV(Required)0123Edema and swelling in ankles and wristsMuscle crampingPoor muscle enduranceFrequent urinationFrequent thirstCrave saltAbnormal sweating from minimal activityAlteration in bowel regularityInability to hold breath for long periodsShallow, rapid breathingCategory XV(Required)0123Tired/sluggishFeel cold―hands, feet, all overRequire excessive amounts of sleep to function properlyIncrease in weight even with low-calorie dietGain weight easilyDifficult, infrequent bowel movementsDepression/lack of motivationMorning headaches that wear off as the day progressesOuter third of eyebrow thinsThinning of hair on scalp, face, or genitals, or excessive hair lossDryness of skin and/or scalpMental sluggishnessCategory XVI(Required)0123Heart palpitationsInward tremblingIncreased pulse even at restNervous and emotionalInsomniaCategory XVI (Cont.)(Required)0123Night sweatsDifficulty gaining weightCategory XVII (Males Only)(Required)0123Urination difficulty or dribblingFrequent urinationPain inside of legs or heelsFeeling of incomplete bowel emptyingLeg twitching at nightCategory XVIII (Males Only)(Required)0123Decreased libidoDecreased number of spontaneous morning erectionsDecreased fullness of erectionsDifficulty maintaining morning erectionsSpells of mental fatigueInability to concentrateEpisodes of depressionMuscle sorenessDecreased physical staminaUnexplained weight gainIncrease in fat distribution around chest and hipsSweating attacksMore emotional than in the pastCategory XIX (Menstruating Females Only)(Required)0123Pain and cramping during periodsScanty blood flowHeavy blood flowBreast pain and swelling during mensesPelvic pain during mensesIrritable and depressed during mensesAcneFacial hair growthHair loss/thinningPerimenopausal(Required) Yes No Alternating menstrual cycle lengths(Required) Yes No Extended menstrual cycle (greater than 32 days)(Required) Yes No Shortened menstrual cycle (less than 24 days)(Required) Yes No Category XX (Menopausal Females Only)(Required)0123Hot flashesMental fogginessDisinterest in sexMood swingsDepressionPainful intercourseShrinking breastsFacial hair growthAcneIncreased vaginal pain, dryness, or itchingHow many years have you been menopausal?(Required)Since menopause, do you ever have uterine bleeding?(Required) Yes No PART IIIHow many alcoholic beverages do you consume per week?(Required)Rate your stress level on a scale of 1-10 during the average week:(Required)How many caffeinated beverages do you consume per day?(Required)How many times do you eat fish per week?(Required)How many times do you work out per week?(Required)How many times do you eat raw nuts or seeds per week?(Required)List the three worst foods you eat during the average week:(Required)List the three healthiest foods you eat during the average week:(Required)PART IVPlease list any medications you currently take and for what conditions:(Required)Please list any natural supplements you currently take and for what conditions:(Required)7-Day Record of Food Intake7-Day Record of Food Intake Name(Required)Start Date(Required) End Date(Required) Each day, record all the items you eat and drink. Be sure to include the approximate amount of each item. Your diet may be the key to better health! Record everything you eat and drink for 7 days. Be as thorough and detailed as possible. Be as honest as you can be. I am gathering data, not judging. Don’t change your normal routine. Just record what you are doing. To measure, simply use hand-sized portions (e.g., 1 palm, 1 fist, 1 cupped handful, 1 thumb) or something else standardized (e.g., baseball, deck of cards). You can use measuring cups or a food scale if you want, but you don’t have to. Record any other notes, such as why you are eating, physical sensations from eating, how you felt after you ate. Day I Date(Required) Meat & Dairy:BREAKFAST Time:LUNCH Time:DINNER Time:Vegetables & Fruits:BREAKFAST Time:LUNCH Time:DINNER Time:Breads, Cereals, & Grains:BREAKFAST Time:LUNCH Time:DINNER Time:Fats {butter, margarine, oils, etc.)BREAKFAST Time:LUNCH Time:DINNER Time:Candy, Sweets, &Junk Food:BREAKFAST Time:LUNCH Time:DINNER Time:Water Intake (fl. Oz.)BREAKFAST Time:LUNCH Time:DINNER Time:Other DrinksBREAKFAST Time:LUNCH Time:DINNER Time:SnacksMID-MORNING SNACK Time:MID-DAY SNACK TimeMID-DAY SNACK TimeBowel Movements (# and consistency)(Required)Hours of Sleep:(Required)Quality of Sleep:(Required) 1 2 3 4 5 (Poor) 1 2 3 4 5 (Excellent)Day 2 Date(Required) Meat & Dairy:BREAKFAST Time:LUNCH TimeDINNER TimeVegetables & Fruits:BREAKFAST Time:LUNCH TimeDINNER TimeBreads, Cereals, & GrainsBREAKFAST Time:LUNCH TimeDINNER TimeFats (butter, margarine, oils, etc.):BREAKFAST Time:LUNCH TimeDINNER TimeCandy, Sweets, &Junk FoodBREAKFAST Time:LUNCH TimeDINNER TimeWater Intake (fl. Oz.)BREAKFAST Time:LUNCH TimeDINNER TimeOther DrinksBREAKFAST Time:LUNCH TimeDINNER TimeSnacksMID-MORNING SNACK TimeMID-DAY SNACK TimeEVENING SNACK Time:Bowel Movements (# and consistency)(Required)Hours of Sleep:(Required)Quality of Sleep:(Required) 1 2 3 4 5 (Poor) 1 2 3 4 5 (Excellent)Day 3 Date(Required) Meat & Dairy:BREAKFAST Time:LUNCH TimeDINNER TimeMeat & Dairy:BREAKFAST Time:LUNCH TimeDINNER TimeVegetables & Fruits:BREAKFAST Time:LUNCH TimeDINNER TimeBreads, Cereals, & GrainsBREAKFAST Time:LUNCH TimeDINNER TimeFats {butter, margarine, oils, etc.)BREAKFAST Time:LUNCH TimeDINNER TimeCandy, Sweets, &Junk Food:BREAKFAST Time:LUNCH TimeDINNER TimeWater Intake (fl. Oz.)BREAKFAST Time:LUNCH TimeDINNER TimeOther Drinks:BREAKFAST Time:LUNCH TimeDINNER TimeSnacksBowel Movements (# and consistency)(Required)Hours of Sleep:(Required)Quality of Sleep:(Required) 1 2 3 4 5 (Poor) 1 2 3 4 5 (Excellent)N01ES:(Required)Day 4 Date(Required) Meat & Dairy:BREAKFAST Time:LUNCH TimeDINNER TimeVegetables & FruitsBREAKFAST Time:LUNCH TimeDINNER TimeBreads, Cereals, & GrainsBREAKFAST Time:LUNCH TimeDINNER TimeFats (butter, margarine, oils, etc.)BREAKFAST Time:LUNCH TimeDINNER TimeCandy, Sweets, &Junk Food:BREAKFAST Time:LUNCH TimeDINNER TimeWater Intake (fl. Oz.)BREAKFAST Time:LUNCH TimeDINNER TimeOther DrinksBREAKFAST Time:LUNCH TimeDINNER TimeSnacksBowel Movements (# and consistency)(Required)Hours of Sleep:(Required)Quality of Sleep:(Required) 1 2 3 4 5 (Poor) 1 2 3 4 5 (Excellent)Day 5 Date(Required) Meat & Dairy:BREAKFAST Time:LUNCH TimeDINNER TimeVegetables & FruitsBREAKFAST Time:LUNCH TimeDINNER TimeBreads, Cereals, & GrainsBREAKFAST Time:LUNCH TimeDINNER TimeFats (butter, margarine, oils, etc.)BREAKFAST Time:LUNCH TimeDINNER TimeCandy, Sweets, &Junk Food:BREAKFAST Time:LUNCH TimeDINNER TimeWater Intake (fl. Oz.)BREAKFAST Time:LUNCH TimeDINNER TimeSnacksBREAKFAST Time:LUNCH TimeDINNER TimeOther DrinksMID-MORNING SNACK TimeMID-DAY SNACK TimeEVENING SNACK Time:Bowel Movements (# and consistency)(Required)Hours of Sleep:(Required)Quality of Sleep:(Required) 1 2 3 4 5 (Poor) 1 2 3 4 5 (Excellent)Day 6 Date(Required) Meat & Dairy:MID-MORNING SNACK TimeMID-DAY SNACK TimeEVENING SNACK Time:Vegetables & FruitsBREAKFAST Time:LUNCH TimeDINNER TimeBreads, Cereals, & GrainsBREAKFAST Time:LUNCH TimeDINNER TimeMFats (butter, margarine, oils, etc.)BREAKFAST Time:LUNCH TimeDINNER TimeCandy, Sweets, &Junk Food:BREAKFAST Time:LUNCH TimeDINNER TimeWater Intake (fl. Oz.):BREAKFAST Time:LUNCH TimeDINNER TimeOther DrinksBREAKFAST Time:LUNCH TimeDINNER TimeDay 7 Date(Required) Meat & Dairy:BREAKFAST Time:LUNCH TimeDINNER TimeVegetables & Fruits:BREAKFAST Time:LUNCH TimeDINNER TimeBreads, Cereals, & GrainsBREAKFAST Time:LUNCH TimeDINNER TimeFats (butter, margarine, oils, etc.)BREAKFAST Time:LUNCH TimeDINNER TimeCandy, Sweets, &Junk Food:BREAKFAST Time:LUNCH TimeDINNER TimeWater Intake (fl. Oz.):BREAKFAST Time:LUNCH TimeDINNER TimeOther Drinks:BREAKFAST Time:LUNCH TimeDINNER TimeSnacksMID-MORNING SNACK TimeMID-DAY SNACK TimeEVENING SNACK Time:Bowel Movements (# and consistency)(Required)Hours of Sleep:(Required)Quality of Sleep:(Required) 1 2 3 4 5 (Poor) 1 2 3 4 5 (Excellent) PAGE 4 Health Questionnaires (NTAF)Name(Required)Age(Required)Sex(Required)Date(Required) SECTION A * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123Is your memory noticeably declining?Are you having a hard time remembering names and phone numbers?Is your ability to focus noticeably declining?Has it become harder for you to learn things?How often do you have a hard time remembering your appointments?Is your temperament getting worse in general?Are you losing your attention span endurance?How often do you find yourself down or sad?How often do you fatigue when driving compared to the past?How often do you fatigue when reading compared to the past?How often do you walk into rooms and forget why?How often do you pick up your cell phone and forget why?SECTION B * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123How high is your stress level?How often do you feel that you have something that must be done?Do you feel you never have time for yourself?How often do you feel you are not getting enough sleep or rest?Do you find it difficult to get regular exercise?Do you feel uncared for by the people in your life?Do you feel you are not accomplishing your life's purpose?Is sharing your problems with someone difficult for you?SECTION C1 * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123How often do you get irritable, shaky, or have lightheadedness between meals?How often do you feel energized after eating?How often do you have difficulty eating large meals in the morning?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 wake up in the middle of the night?How often do you have difficulty concentrating before eating?How often do you depend on coffee to keep yourself going?How often do you feel agitated, easily upset, and nervous between meals?SECTION C2 * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123Do you get fatigued after meals?Do you crave sugar and sweets after meals?Do you feel you need stimulants such as coffee after meals?Do you have difficulty losing weight?How much larger is your waist girth compared to your hip girth?How often do you urinate?Have your thirst and appetite been increased?Do you have weight gain when under stress?Do you have difficulty falling asleep?SECTION 1 - S * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123Are you losing your pleasure in hobbies and interests?How often do you feel overwhelmed with ideas to manage?How often do you have feelings of inner rage (anger)?How often do you have feelings of paranoia?How often do you feel sad or down for no reason?How often do you feel like you are not enjoying life?How often do you feel you lack artistic appreciation?How often do you feel depressed in overcast weather?How much are you losing your enthusiasm for your favorite activities?How much are you losing enjoyment for your favorite foods?How much are you losing your enjoyment of friendships and relationships?How often do you have difficulty falling into deep restful sleep?How often do you have feelings of dependency on others?How often do you feel more susceptible to pain?How often do you have feelings of unprovoked anger?How much are you losing interest in life?SECTION 2 - D * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123How often do you have feelings of hopelessness?How often do you have self-destructive thoughts?How often do you have an inability to handle stress?How often do you have anger and aggression while under stress?How often do you feel you are not rested even after long hours of sleep?How often do you prefer to isolate yourself from others?How often do you have unexplained lack of concern for family and friends?How easily are you distracted from your tasks?How often do you have an inability to finish tasks?How often do you feel the need to consume caffeine to stay alert?How often do you feel your libido has been decreased?How often do you lose your temper for minor reasons?How often do you have feelings of worthlessness?SECTION 3 - G * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123How often do you feel anxious or panic for no reason?How often do you have feelings of dread or impending doom?How often do you feel knots in your stomach?How often do you have feelings of being overwhelmed for no reason?How often do you have feelings of guilt about everyday decisions?How often does your mind feel restless?How difficult 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 not worried about before?How often do you have feelings of inner tension and inner excitability?SECTION 4 - ACH * Please circle the appropriate number “0 - 3” on all questions below. 0 as the least/never to 3 as the most/always.(Required)0123Do you feel your visual memory (shapes & images) is decreased?Do you feel your verbal memory is decreased?Do you have memory lapses?Has your creativity been decreased?Has your comprehension been diminished?Do you have difficulty calculating numbers?Do you have difficulty recognizing objects & faces?Do you feel like your opinion about yourself has changed?Are you experiencing excessive urination?Are you experiencing slower mental response? PAGE 5 Medication History* Please check any of the following medications you have been on or are currently taking. Acetylcholine Receptor Antagonist – Antimuscarinic Agents(Required) Atropine Ipratopium Scopolamine Tiotropium None Acetylcholine Receptor Antagonist - Ganlionic Blockers(Required) Mecamylamine Hexamethonium Nicotine (high doses) Trimethaphan None Acetylcholinesterase Reactivators(Required) Pralidoxime None Acetylcholine Receptor Antagonist - Neuromuscular Blockers(Required) Atracurium Cisatracurium Doxacurium Metocurine Mivacurium Pancuronium Rocuronium Succinylcholine Tubocurarine Vecuronium Hemicholinium None Agonist Modulator of GABA Receptor (benzodiazepines)(Required) Xanax® Lexotanil Lexotan® Librium Klonopin® Valium® ProSom® Rohypnol Dalmane Ativan Loramet® Sedoxil Dormicum Megalodon Serax® Restoril Halcion None Agonist Modulator of GABA Receptors (nonbenzodiazepines)(Required) Ambien CR® Sonata® Lunesta® Imovane None Cholinesterase Inhibitors (irreversible)(Required) Echotiophate Isoflurophate Organophosphate Insecticides Organophosphate-containing nerve agents None Cholinesterase Inhibitors (reversible)(Required) Donepezil Galatamine Rivastigmine Tacrine THC Edrophonium Neostigmine Physostigmine Pyridostigmine Carbamate Insecticides None Dopamine Reuptake Inhibitors(Required) Wellbutrin XL® (Bupropion) None Dopamine Receptor Agonists(Required) Mirapex® Sifrol® Requip® None D2 Dopamine Receptor Blockers (antipsychotics)(Required) Thorazine® Prolixin® Trilafon® Compazine® Mellaril® Stelazine® Vesprin® Nozinan® Depixol® Navane® Fluanxol® Clopixol® Acuphase® Haldol® Orap® Clozaril® Zyprexa® Zydis® Seroquel XR® Geodon® Solian® Invega® Abilify® None GABA Antagonist Competitive binder(Required) Flumazenil None Monoamine® Oxidase Inhibitors (MAOI)(Required) Marplan® Aurorix® Manerix® Moclodura Nardil Adeline® Eldepryl® Azilect® Marsilid® Iprozid® Ipronid® Rivivol Popilniazida® Zyvox® Zyvoxid® None Noradrenergic® and Specific Sertonergic ® Antidepressants (NaSSaa)(Required) Remeron®, Zispin® Avanza® Norset® Remergil® Axit® None Selective Serotonin Reuptake Inhibitors(Required) Paxil® Zoloft® Prozac® Celexa® Lexapro® Luvox® Cipramil® Emocal® Seropram® Cipralex® Esteria® Fontex® Dapoxetine® Seromex® Seronil® Sarafem® Fluctin® Faverin® Seroxat Aropax® Deroxat® Rexetin® Paroxat® Lustral® Serlain® None Selective Serotonin Reuptake Enhancers(Required) Stablon® Coaxil Tatinol® None Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)(Required) Effexor® Pristiq® Meridia Serzone® Dalcipran® Despiramin Duloxetine None Tricylic Antidepressants (TCAs)(Required) Elavil® Endep® Tryptanol Trepiline® Asendin® Asendis® Defanyl® Demolox® Moxadil® Anafranil® Norpramin® Pertofrane® Prothiaden® Adapin® Sinequan® Tofranil® Janamine® Gamanil® Aventyl® Pamelor® Opipramol® Vivactil® Rhotrimine® Surmontil® None
