Fibromyalgia, Hypothyroidism, Thyroid Hormone Resistance

Evaluation Forms
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The Metabolic Treatment
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by Dr. John C. Lowe
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Sets of Forms

Latest Updates to drlowe.com

Below are three sets of forms in pdf format. Readers of drlowe.com are free to download and/or print the forms. If you need assistance in downloading or printing the forms, please phone Tammy Lowe at (603) 391-6061 or write to her to at Tammy@drlowe.com. Adobe Reader can be downloaded and used free.

First Set. The forms in the first set are those patients must fill out and submit to the clinic for the doctor to learn whether they are candidates for metabolic rehab.

Second Set. The forms in the second set are for patient to fill out at intervals during their metabolic rehab. The purpose in these forms is for the doctor to evaluate the  patient's changing metabolic health status.

Third Set. The third set of forms is for patients to use when they're guiding their own metabolic rehab. The forms are best used in conjunction with the step-by-step instructions the doctor gives in the book Your Guide to Metabolic Health.

Fourth Set. The fourth set of evaluation forms are for those who have taken charge of their own treatment program. You can, of course, share the forms with a cooperative health care practitioner, if you have one.

One form is a blank monitoring sheet, which we call an "individualized monitoring form." It contains spaces for recording four basal measurements: your armpit temperature, heart rate, blood pressure, and body weight. The monitoring form also contains symptom severity scales. You should label each scale with the name of a predominant symptom that you want to be free from. Fatigue and hair loss are examples. The first scale is already label "Low sense of well-being."

The second form is an overstimulation form. It contains 20 of the most common symptoms of overstimulation. This form is to help you and your clinician detect and properly deal with early indications of overstimulation.

Instructions for using the form are at the top of the form. When you evaluate your health status, collect the appropriate information and fill out both forms. The forms will provide a running record of your changing status as you progress through your treatment program.

If you need help in setting up or guiding yourself through treatment, Dr. Lowe provides long-distance consulting. To inquire about consulting, please see our webpage on consulting and contact Tammy Lowe at Tammy@drlowe.com.

Please note: Providing these forms does not imply that Dr. Lowe nor those individuals who work under their auspices enter a doctor/patient relationship with any person who prints or downloads the forms. The forms are provided strictly for the convenience of readers of drlowe.com. Dr. Lowe and those individuals who work under their auspices are not responsible in any way for those who download or print the use the forms and use them.

First Set: Forms for Initial Evaluation

Case History Form

New Patient FibroQuest Form

Body Drawings

Fibromyalgia Impact Questionnaire

Zung's Scale

Overstimulation Form

Second Set: Forms for Reevaluations
During Metabolic Rehab


FibroQuest Form

Body Drawings

Fibromyalgia Impact Questionnaire

Zung's Scale

Overstimulation Form

Third Set: Forms for Self-Guided Metabolic Rehab

Symptoms Severity Scales

Symptoms Graph

Overstimulation Form

Fourth Set.

Individualized Monitoring Form

Overstimulation Form

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