DR.

HEDAYAS PSYCHO-METABOLIC QUESTIONNAIRE

The National Centers for Whole Psychiatry NAME ________________________________ DATE _______________ Please score the items you experience on a scale of 0-4: 0 (I do not experience this) 1 (This is a mild problem) 2 (This is a significant problem) 3 (This is a major problem) 4 (This is a severe problem) Medications:____________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ wholepsych.com phone: 301-657-4749 ____ Salt craving _____

TOTAL

3
____ Over 50 years old ____ Food sits in stomach, burping after meals, constipation, Celiac disease, gastric bypass ____White spots on arms, Chrons disease ____ On birth control pills, stimulants, antidepressants, acid-blocking medicines (e.g. Prilosec, Pepsid, Tagamet, Nexium) Glucophage, Metformin ____ Numbness ____ Tingling ____ Balance problems ____ Depression ____ Weakness in any body part ____ Autoimmune disease ____ Vegetarian diet ____ Fatigue TOTAL _____

1
____ Diarrhea ____ Constipation ____ Food sittting in stomach after meals ____ Acid-stomach ____ Gassiness ____ Burping or belching ____ Cramping ____ Bloating ____ Frequent coughing ____ Bloody stools TOTAL _____

4
____ Pregnancy ____ Regular or binge alcohol consumption ____ Food sits in stomach, burping after meals, constipation, Celiac disease, gastric bypass ____ On anti-convulsant medication, Met formin, Glucopphage, Sulfasalazine, Triampterene, Methotrexate, barbiturates ____ Depression ____ Anemia ____ Weakness ____ Headaches ____ Reduced appetite ____ Diarrhea ____ Sore tongue ____ Palpitations ____ Irritability ____ Forgetfulness

2
____ Difficulty handling stress ____ Poor sleep ____ Exhaustion ____ Scars which heal darkly ____ Dizziness on standing ____ Low blood pressure

2009 Dr. Robert Hedaya This form may only be reprinted as is without changes.

DR. HEDAYAS PSYCHO-METABOLIC QUESTIONNAIRE

The National Centers for Whole Psychiatry _____ wholepsych.com phone: 301-657-4749 ____ High triglycerides _____

TOTAL

TOTAL

5
____ Numbness ____ Tingling ____ Kidney stones ____ Carpal tunnel syndrome ____ Antidepressant medications, stimulants, caffeine, birth control pills TOTAL _____

9
____ Emotional lability ____ Depression ____ Post partum depression ____ Impaired immunity, frequent colds/infections ____ Recent growth spurt ____ White spots on nails, ____ Slow wound healing, ____ Stretch marks ____ Growth retardation ____ Hair loss ___ Decreased libido ___ Trouble with memory or word finding ___ Osteoporosis ___ Loss of appetite ___ Celiac Disease (gluten sensitivitywheat/oats/rye/barley) ___ Regular or binge alcohol use ___ Altered taste ___ Vegetarian diet TOTAL _____

6
____ Psychosis ____ High cholesterol ____ Dermatitis ____ Skin: red, sensitive to sun, thickened ____ Diarrhea ____ Appetite loss ____ Beefy red tongue ____ Apathy ____ Co-ordination problems ____ Numbness ____ Tingling ____ Dementia TOTAL _____

7
____ Frequent or binge use of alcohol ____ Diet high in sweets, carbs TOTAL _____

10
____ African American (no score; just check) ____ Indoor occupation or home bound ____ Northern climate ____ Use sun block ____ Depression ____ Osteoporosis ____ Hypertension ____ Muscle or bone pain ____ Fatigue ____ Frequent infections or inflammatory diseases ____Over 60 (no score; just check) ____Obese TOTAL _____

8
____ Low intake of fish, green leafy vegetables ____ Dry skin ____ Dry hair ____ Thyroid dysfunction ____ Illnesses associated with inflammation (e.g. any it is, such as arthritis, bursitis, prostatitis etc) ____ Cardiovascular disease ____ Depression

2009 Dr. Robert Hedaya This form may only be reprinted as is without changes.

DR. HEDAYAS PSYCHO-METABOLIC QUESTIONNAIRE

The National Centers for Whole Psychiatry wholepsych.com phone: 301-657-4749

11
____ Chronic Stress ____ Dizziness when you stand or bend ____ Low Blood pressure ____ Craving salty foods-pretzels, pickles ____ Easy bruising ____ Fatigue ____ Inability to handle even slight stresses ____ Hypoglycemia: dizzy, irritable, or sleepy if you go without food for 4-5 hours; symptoms relieved by food ____ Scars, elbows, nipples, that are unusually dark ____ Slow healing of cuts ____ Unstable body temperatures (hot or cold) TOTAL _____

____ Breast tenderness ____ Depression ____ Bloating ____ Cramping ____ Other ________________________ ___________________________________ ___________________________________ ________________________ ____ Infertility ____ Irregular menstrual cycles How long? _________ ____ Short cycles ____ Long cycles ____ On birth control pills: How long?_________ ____ In menopause: How long? _______
(no score; just check)

12
____ Weight gain around your abdomen and in the face and cheeks ____ Stretch marks-not from weight loss ____ Adult onset diabetes ____ Osteoporosis ____ Craving sweets ____ Trouble falling or staying asleep TOTAL ____

____ Trouble with short term memory ____ Trouble learning new things ____ Vaginal dryness ____ Loss of sex drive ____ Hot flashes TOTAL _____

15
____ Depressed mood ____ Lack of energy ____ Reduced sex drive ____ Loss of morning erection, erection less strong, trouble maintaining erection ____ Reduced muscle strength ____ Memory problems ____ Increased abdominal fat ____ Osteoporosis ____ Fractures in recent years ____ Low sperm count ____ Thinning or loss of male hair pattern ____ Change in voice ____ Reduced concentration ____ Loss of height ____ Loss of pleasure ____ Deterioration in work performance ____ Falling asleep after dinner TOTAL _____

13
____ Excessive dark male pattern hair growth ____ Irregular or no periods ____ Eastern European heritage TOTAL _____

14
____ PMS - note symptoms: ____ Irritability ____ Cravings

2009 Dr. Robert Hedaya This form may only be reprinted as is without changes.

DR. HEDAYAS PSYCHO-METABOLIC QUESTIONNAIRE

The National Centers for Whole Psychiatry wholepsych.com phone: 301-657-4749

16
____ Low energy ____ Dry skin ____ Hair falling out more than normal ____ Muscle weakness: going up stairs, getting out of cars, opening jars ____ Sensitivity to cold ____ Constipation ____ Irregular/heavy/light periods ____ Hoarseness ____ Puffiness under eyes ____ Puffy legs ____ Brittle nails ____ Weight gain ____ Snoring ____ Slowness in thinking ____ Problems with concentration ____ Trouble falling asleep ____ Outer third of eyebrows thin ____ Low body temperature TOTAL _____

____ Gluten sensitivity (Celiac disease) ____ - itis diseases(e.g., arthritis, colitis, prostatitis, diverticulitis, thyroiditis, sinusitis etc. ____ Auto-immune disease (lupus, pernicious anemia, rheumatoid arthritis, multiple sclerosis, etc) ____ HIV ____ Chronic infections (periodontal gum disease, sinusitis, Lyme disease, infected root canals, yeast infections etc) ____ Osteoporosis ____ Brain fog ____ Reduced short term memory ____ Trouble finding words ____ Feeling confused with simple tasks ____ Learning disabilities ____ Feel like lying in bed all day ____ Fevers or chills ____ Night sweats ____ Muscle or joint aches and pains ____ Feeling swollen all over ____ Pain ____ Gastrointestinal problems ____ Zinc spots on nails ____ Acne ____ Recent growth spurt ____ Irritability ____ Unusual graying of hair ____ Lots of sweets or breads or fats in diet ____ Food allergies/sensitivities ____ Raccoon Eyes ____ Easy and prolonged blanching of skin after pressure or mottled/uneven skin color ____ Flooding or wet basement ____ Mold in home ____ Allergies ____ Diabetes ____ Regular or binge alcohol use ____ Many mercury fillings, eating lots of tuna fish TOTAL _____

17
____ Excess energy ____ Oily skin ____ Tremor ____ Unexplained weight loss ____ Rapid or pounding heartbeat ____ Decreased need for sleep ____ Eyes bulging ____ Diarrhea ____ High body temperature TOTAL _____

18
____ High cholesterol ____ High triglycerides ____ Hypertension ____ Abdominal weight/large waist ____ Heart disease ____ Inflammatory bowel disease (Chrons Disease) ____ Frequent diarrhea

2009 Dr. Robert Hedaya This form may only be reprinted as is without changes.

DR. HEDAYAS PSYCHO-METABOLIC QUESTIONNAIRE

The National Centers for Whole Psychiatry wholepsych.com phone: 301-657-4749

Practitioner Interpretive Key

The goal of this intake sheet is to give you an idea of how biological systems may be affecting a patients mental health, and where a medical referral for treatment or testing may be indicated. Instructions: Add up the patients totals for each numbered section. Enter them below over the highest possible score for each section. The totals will indicate which areas to focus on. Scores are not absolute, but become more relevant as they approach the highest score possible in each category. Totals/ System Action highest score 1. Digestion 2. B5 (pantothenic acid) 3. B12 4. Folic Acid 5. B6 (pyridoxine) 6. B3 7. B1 (thiamine) 8. Essential Fatty Acids (Omega 3s) 9. Zinc 10. Vitamin D 11. Adrenal Fatigue 12. Cushings syndrome/excess cortisol 13. Inherited adrenal hyperplasia/excess male hormone and reduced cortisol 14. Estrogen & progesterone 15. Testosterone 16. Hypothyroid 17. Hyperthyroid 18. Immunity & Inflammation Notes: /40 /28 /48 /56 /20 /48 /8 /32 /72 /40 /44 /24

/12 /72 /68 /72 /36 /160

2009 Dr. Robert Hedaya This form may only be reprinted as is without changes.