Symptom Survey
No Student left behind
Education and
Wellness Institute
Your Doctor relies on Symptoms and Blood Test to help Diagnose your Disease or Condition.

Do you have enough time during your office visit to tell your Doctor all of your Symptoms? As you know, Doctors
have a limited amount of time to spend with each patient.

Now you have an opportunity to view some 212 questions that you may want to ask your Doctor. These questions
are divided into 8 different Groups with Group 7 having 6 different Sections. There is also a section especially for
Women and Men.

Each Group and Section can indicate Nutritional Deficiencies in different parts of the body, from Acid food upset to
Constipation.

How to use the Symptom Survey:
1. Click on the one of the Survey pages 1-4 to enlarge. You can then copy and print each page.
2. Read each question. If the question doesn't apply to you, leave it blank. If it does apply to you, circle 1,2 or 3
depending on severity.
3.
Add up the numbers for each Group individually from Group 1- 6. In group 7 add up the numbers for
each Section from A - F.
4. Add up the numbers for Group 8 and for either Female or Male.

Write the totals next to the Group or Section.

Example: Totals for,
Group (GP) 1 = 5
GP 2 = 8
GP 3 = 0
GP 4 = 7
GP 5 = 4
GP 6 = 3
GP 7A = 1
GP 7B = 5
GP 7C = 8
GP 7D = 0
GP 7E = 7
GP 7F = 4
GP 8 = 15
Female Only or Men only = 10

Important: Please list the five main physical Complaints you have in order of importance.

Also copy and complete the two Toxicity questionnaires and the Hair Analysis current Diagnosis forms.

Blood Pressure readings: While lying down or sitting, take your
Blood Pressure twice on the right arm first and
record the results.. Next, do your Blood Pressure on the left arm twice and record your readings. Next, while the
Blood Pressure cuff is on the left arm, stand and immediately take your Blood Pressure and record your readings.

The Blood Pressure readings should be similar on both right & left arm. When you stand, the Blood Pressure
should rise about 10 points
(Adrenal function) according to Medical Doctors who study Functional Endocrinology.
The Pressure should be 120/80 on both sides. If there is substantial difference between the Systolic (high number)
pressure from right to left, contact your Medical Doctor.

This information gained is NOT to Diagnose any Disease of Condition. You already have a Diagnosis from your
doctor. If your Doctor is not sure about your condition, the information gathered from all your Symptoms may help
provide your Doctor additional information for him/her to come to a Diagnosis.


After filling out the four pages of the questionnaire and the two pages of the Toxicity Questionnaire, you can scan
them to email them to us. We are asking a Donation from you to provide this service and help support our
nonprofit organization.

To review your Symptoms and Toxicity Questionnaire, we request a Donation of $30. Donate now.

After we receive your Donation, we will send you the email address to send your Symptom Survey and Toxicity
Questionnaires.

A Toxicity Questionnaire is located at the bottom of this page.

Symptom Survey Forms 1-4:
Click on forms to enlarge and copy.
















Page 1                                         Page 2                                        Page 3                                      Page 4

Toxicity Questionnaire 1&2:  
Click on Forms to enlarge.
Read the instructions and fill it out. It is self explanatory. If any individual section is 6 or more or the grand total is
40 or more, you may have TOXINS in your body.                                
















Toxicity Questionnaire 1                     Toxicity Questionnaire 2            Hair Analysis current diagnosis

If your total number suggest you are TOXIC, getting a Nutritional Hair Mineral Analysis would help determine what
Toxins have accumulated in your body. See
Hair Analysis for details.



The information on the website has not been evaluated by the Food and Drug Administration. The
information and products on this site are not intended to diagnose, treat, cure or prevent any disease.
Before using any of the information or products, please consult your doctor