Metabolic Health Assessment · CleanUP

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Name

Date

Part 1

Check anything that applies to you. (These help us understand your picture — they aren't scored.)

Part 2

List your 5 most prominent health concerns, in order of importance.

Part 3

Read each description and choose the number that best describes how often you've had that symptom in the past year. If you don't understand a symptom, leave it at 0.

0 Never · 1 Mild (once a month or less) · 2 Moderate (several times a month) · 3 Severe (aware of it constantly)

Your progress

Part 1

Part 2

Part 3