Personal History Gender
Current Health Conditions
Health History
Past Medical History (Please check all that apply and date.) Past Medical History
General Please check all symptoms that apply to you now (check) or in the past (mark with P)
Women Select
Muscle, Joints And Bones Select Pains
Brain, Nerve And Emotions Select
Stress
Current Stress Level 1 to 10 (10 being highest, 0 being no stress):
How long have you felt like this? What would you describe as the three dominant emotions in your life at this time? (Example include happiness, fear, sadness, anxiety, frustration, anger, grief, heartache, contentment, excitement, lethargix, moody, stressed, etc.)
Family History
Please list state of health and major illnesses that members of your family have had. If relevant, include at what age they died (and what they died of). or adopted, unknown
Activity
Write down the number of hours (to the half) per day you spend sedentary (lying or sitting down) in each of the following.
Habits
Food And Diet
Please describe your general diet. If there is anything you would like to add, please feel free to do so. If you have any questions or concerns you would like addressed, you may write them here. This may include your health story, or how you believe you came to your health challenges.
Metabolic Assessment Form
Part 1 Please list your 5 major health concerns in order of importance
Part 2
Part 3 Category 1
Feeling that bowels do not empty completely Lower abdominal pain relieved 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 daily Use laxatives frequently Nausea after meals Category 2
Increasing frequency of food reactions Unpredictable food reactions Aches, pains ans swelling throughout the body Unpredictable abdominal swelling Frequent bloating and distention after eating Abdominal intolerance to sugars and starches Category 3
Intolerance to smells Intolerance to jewelry Intolerance to shampoo, lotion, detergents, etc. Multiple smell and chemical sensitivities Constant skin outbreaks Category 4
Excessive belching, burping, or bloating Gas immediately following a meal Offensive breath Difficult bowel movement Sense of fullness during and after meals Difficulty digesting fruits and vegetables Undigested food found in stools Category 5
Stomach pain, burning, of aching 1-4 hours after eating Use antacids
Liability Waiver for Maas Method, LLC authorize Maas Method, LLC to perform services to develop a natural, complementary health improvement program for me in order to assist me in improving my overall health and not for the treatment or “cure” of any disease.
