Evaluation forms

You’ll find that there are three different sets of evaluation forms. One is for your initial evaluation and the other two are for monitoring your progress with metabolic rehab. Please feel free to call the Center if you have any questions about which set you need to download and send to us. The forms are in pdf format. You will need to have Adobe Reader installed in your computer to download and open the files for the forms.

Adobe Reader 8 is the current version of this free software and you can find it at http://www.adobe.com/products/acrobat/readstep2.html

If you aren’t sure whether or not you would be a good candidate for metabolic rehab, please go ahead and fill out the initial evaluation forms. You can either fax or snail mail them to the Center and Dr. Honeyman will review them (at no cost) to help determine if you are a good candidate for metabolic rehab.

1. Initial evaluation forms

Dr. Honeyman wants to look over your initial evaluation forms before she sees you in the clinic for your metabolic evaluation. She wants to be sure that your symptoms are consistent with those of a patient with hypometabolism before you schedule an appointment. Please take your time when you fill them out so Dr. Honeyman gets the most complete information that you can provide. When you come in for your evaluation, she will already be familiar with your health history. By doing this, more of your time with her will be spent on developing your treatment plan and learning how to fully engage in metabolic rehab.

This set includes:

Body diagram to shade in areas where you have pain (pdf)
Case History (2 pages) (pdf)
FibroQuest form (4 pages) (pdf)
Fibromyalgia Impact Questionnaire (FIQ) (pdf)
Zungs’ Self-Rating Depression Inventory (pdf)
“Are you overstimulated?”(pdf)

Be sure to fill out the “Are you overstimulated?” form even if you are not yet taking thyroid hormone or don’t suspect that you are overstimulated. This form will give you and Dr. Honeyman a reference point to work from as you discuss the possibility of overstimulation as you progress with treatment. This set includes:

2. Monitoring forms

The second set is for people who are going to send in forms to the Center for ongoing monitoring of their responses to treatment. Many of the forms are the same ones that you filled out prior to coming in for your metabolic evaluation. You can still participate with this system of monitoring even if you didn’t come in for an evaluation. This system of monitoring is simpler for most people since you fill out the forms, fax or snail mail them to the Center, and we will score and graph the data for you. A 15-minute telephone consultation is included with the fee for this type of monitoring.

This set of forms includes:

Body diagram (pdf)
FibroQuest (pdf)
FIQ (pdf)
Zung’s (pdf)
“Are you overstimulated?” (pdf)

3. Do-it-yourself monitoring forms

The third set is for people who want to monitor and graph their responses on their own.
Chapter 3 in “Your Guide to Metabolic Health” describes how to monitor yourself.

This set includes:

Blank visual analog scales - you decide which symptoms to track (pdf)
Graph paper (pdf)
“Are you overstimulated?” (pdf)

Monitoring your responses is a simple process once you understand how to do it. Metabolic rehab is a precise, data-driven treatment protocol, so your success depends on monitoring at regular intervals. If you aren’t monitoring your responses with one of these methods, you are not actually engaging in metabolic rehab. Please call us at 303.413.9100 if you need help with your monitoring.

Other forms

Telephone consult authorization form (pdf)