Toxicity Questionnaire & Disclaimer
 
 
 
 
Nutrition Wellness Center
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 


 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 

 

 

 

 

 

 

 

 

 

  

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

"Why this HEALTH SURVEY can help you resolve Your Health Problems"

Most people think that what causes high blood pressure, chronic pain, allergies, frequent headaches, weight gain and chronic fatigue are the same reasons for everyone.

This is absolutely false. What causes specific symptoms in one person could have a totally different cause for the same symptoms in another person. I have seen this repeatedly for the last thirty years…same symptoms, different cause. This is why the shotgun approach doesn't work for most people.

I am sure you know someone who has lost weight on a particular weight loss program but it didn't work for you. The same is true for all other symptoms. Another good example is allergies, in one person it may be a gut issue, in another person it may be an adrenal issue, or even a liver issue. Addressing the individual as an individual produces the best results.

That's why you are taking this individualized HEALTH SURVEY….to pinpoint the organs or glands that are not functioning at their optimum level. Then and only then, do you have a map to address the cause of your specific health issues. Make sense?

I can tell you from my thirty plus years of experience--addressing the "CAUSE" versus treating the symptoms has been the only way to resolve health issues, at the same time creating an optimum healthy person.

I have spent years modifying and fine-tuning this survey to improve its accuracy. An imbalance in an organ or system that may show up on your survey may not make sense to you regarding your symptoms. I can assure you--in most cases--it is the organ or systems that need addressing, in order to help resolve your health issues and make you a healthier person as well.

We are happy to discuss any questions you have regarding your survey results…we will explain what you may not be knowledgeable about regarding your survey results.

Read instructions below

 

INSTRUCTIONS:  Select the boxes which apply to you.  MILD symptoms (occur once or twice a year), MODERATE symptoms (occur several times a year), or SEVERE symptoms (you are aware of it almost constantly).

You may notice that some questions are repeated in different sections.  The reason for this is that the same symptoms can occur as a result of less than optimal function from different body systems/organs.

Sympathetic Nervous System - Group 1 A
1. Heart pounds after retiring
2. Appetite reduced
3. Cold sweats often
4. Cuts heal slowly
5. Dry mouth eyes nose
6. Gag easily
7. Fever easily raised
8. Extremities cold clammy
9. Get chilled often
10. Acid foods upset
 
11. Keyed up; fail to calm
12. 'Lump' in throat
13. Neuralgia-like pain
14. Pulse speeds after meals
15. 'Nervous' stomach
16. Sour stomach frequent
17. Staring; blinks little
18. Strong light irritates
19. Unable to relax; startles easily
20. Urine amount reduced
Parasympathetic Nervous System - Group 1 B
1. Gagging reflex slow
2. 'Slow starter'
3. 'Butterfly' stomach cramps
4. Difficulty swallowing
5. Eyes blink often
6. Hoarseness frequent
7. Indigestion soon after meals
8. Subject to colds asthma bronchitis
9. Gets 'chilled' infrequently
10. Perspire easily
11. Eyelids swollen puffy
 
12. Joint stiffness after arising
13. Pulse slow; feels irregular
14. Muscle leg toe cramps at night
15. Eyes or nose watery
16. Constipation diarrhea alternating
17. Breathing irregular
18. Digestion rapid
19. Vomiting frequent
20. Circulation poor sensitive to cold
21. Always seems hungry feels 'light headed' often
Pancreas - Group 2
1. History of cataracts
2. Obesity
3. Thirsty often
4. Hungry often
5. History of Tuberculosis
6. Gum and teeth problems
7. Pain around left shoulder blade
8. Calf pain when walking; resting relieves
9. Losing weight
10. Light (clay) colored stools
11. Carbuncles
12. Boils or skin eruptions
13. Muscle cramps
 
14. Cough up yellow or green mucous
15. Breath smells 'Fruity'
16. Pains in joints
17. Can't hold breath for more than 10-15 seconds
18. Fatigue
19. High blood pressure
20. Diabetes
21. Dry skin
22. Slow healing of wounds
23. Long-standing lower back pain
24. Pain on left side of abdomen
25. Allergic to some foods
Heart/Cardiovascular - Group 3
1. Noises in head or 'ringing in ears'
2. Get 'drowsy' often
3. Tendency to anemia
4. High altitude discomfort
5. Opens windows in closed room
6. Susceptible to colds fevers
7. Aware of 'breathing heavily'
8. High Cholesterol
9. History of poor circulation
10. Sigh frequently; 'air hunger'
11. Swollen ankles worse at night
12. Bruise easily 'black and blue' spots
 
13. Shortness of breath on exertion
14. Dull pain in chest or radiating into left arm; worse on exertion
15. Afternoon 'yawner'
16. History of heart attack
17. No luna (half moons) on figernails
18. Muscle cramps worse during exercise; get 'charley horses'
19. 'Nose bleeds' frequent
20. Hands and feet go to sleep easily; numbness
21. Tension under breastbone or feeling of 'tightness' worse on exertion
22. History of stroke problems
23. High blood pressure
Liver/Gallbladder - Group 4
1. Crave sweets
2. Sneezing attacks
3. Burning feet
4. Use laxatives
5. Itching skin and feet
6. Worrier feels insecure
7. Bitter metallic taste in mouth in mornings
8. History of gallbladder attacks or gallstones
9. Burning or itching anus
10. Excessive falling hair
11. Feeling queasy; headache over eyes
12. Greasy foods upset
13. Stools light-colored
 
14. Bad breath (halitosis)
15. Pain between shoulder blades
16. Blurred vision
17. Nightmare type bad dreams
18. Bowel movements painful or difficult
19. Dry skin
20. Stools alternate from soft to watery
21. Skin peels on foot soles
22. Dairy products cause distress
23. Sensitive to hot weather
24. History of high cholesterol
25. Dizziness
Digestion - Group 5
1. History of ulcers
2. Lower bowel gas several hours after eating
3. Burning stomach sensation eating relieves
4. Diarrhea
5. Constipation
6. Gas shortly after eating
7. Mucous colitis or 'irritable bowel'
 
8. Indigestion 1/2 - 1 hour after eating; maybe up to 3-4 hours
9. Pass large amounts of foul-smelling gas
10. Coated tongue
11. Stomach 'bloating' after eating
12. Loss of taste for meat
13. Cracks down center of tongue
Kidney - Group 6
1. Protein in urine
2. High blood pressure
3. Kidney stones
4. Bladder infection
 
5. Kidney infection
6. Low back pain below the ribs
7. Edema (swelling) in legs feet
8. Teeth marks on both sides of the tongue
Hyperthyroid - Group 7 A
1. Tremors
2. Sensitive to light
3. Protruding eyes
4. Highly emotional
5. Irritable and restless
6. Thin moist skin
7. Can't work under pressure
8. Tension headaches
9. Flush easily
10. Increased sweating
11. Inward trembling
12. Heart palpitates
13. Dry mouth; thick ropy saliva
 
14. Get colds bronchitis
15. Night sweats
16. Can't gain weight
17. Prone to cavities
18. Brittle fingernails
19. Insomnia
20. Dilated pupils
21. Reduced tearing of eyes
22. Burning stomach
23. Body temperature higher
24. Increased blood pressure
25. Gag easily
26. Sweating hands and feet
Hypothyroid - Group 7 B
1. Urinate frequently
2. Stiff or 'cracking' joints
3. Hearing impaired
4. No period
5. Little or no perspiration
6. Sensitive to cold
7. Dry mouth
8. Hair coarse; falls out
9. Mentally sluggish Ringing in ears
10. Constipation
11. Sleepy during day
12. Slow pulse
 
13. Increase in weight
14. Fatigue easily
15. Fingers feel 'dead'
16. Losing outer eyebrow hair
17. Decrease in appetite
18. Always cold
19. Lack of initiative
20. Dry or scaly skin
21. Ringing in ears
22. Heavy menstrual flow
23. Dull headaches in A.M. then taper off
24. Inability to tolerate stress
Hyperpituitary - Group 8 A
1. Allergic skin diseases
2. Restless
3. Very sensitive hearing
4. Headaches 'splitting' type
5. Reactions from eating sugar
6. History of mononucleosis
7. Heavy hair growth on legs and chest
8. Digestive upsets often
 
9. Mind races
10. Increased sex drive
11. Sex drive very strong overexcited
12. Failing memory
13. Temperamental
14. Low blood pressure
15. Rapid shallow breathing
Hypopituitary - Group 8 B
1. Constipation
2. High threshold of pain
3. Headaches start above the ears
4. Sex drive reduced or lacking
5. Low blood pressure
6. Chronic indigestion; subject to ulcers
7. History tendency to ulcers
8. Weak fatigued muscles
9. Lethargic
10. Abnormal thirst
 
11. Epileptic attacks
12. Crave sugar
13. Tend to be inactive
14. Poor circulation
15. Bloating of abdomen
16. Often feel passive
17. Weight gain around hips and/or breasts
18. Headaches before or during periods
19. Young girls--lack of menstruation
Hypothalamus - Group 9
1. Blank spots in vision
2. Diabetes
3. Depression
4. Large amounts of water urinated
5. Body temperature hard to control
6. Breasts produce too much or produce milk when not breastfeeding
7. Heavy thirst
8. Women: puberty started
9. Anxiety
10. Headaches
11. High blood pressure
12. Sleep long hours
 
13. Anorexia
14. Vomiting
15. Bulimia
16. History of head injuries
17. No thirst
18. Obesity
19. Recreational drug abuse before age 8
20. Men: puberty started before age 10
21. Thirsty often
22. Period has stopped or never started
23. Fits of rage
Hyperadrenal - Group 10 A
1. Menstrual related depression
2. Wounds heal poorly
3. Osteoporosis
4. Fat buildup where neck and back meet
5. Thick or heavy eyebrows
6. Severe emotional swings
 
7. Moon face
8. Low backache
9. Excessive hair growth (women)
10. Dilated pupils
11. Increased or high blood pressure
Hypoadrenal - Group 10 B
1. Arthritic tendencies
2. Poor circulation
3. Fatigue
4. Skin color changes
5. Depressed
6. Weakness
7. Intolerant to cold
8. Use diet pills
 
9. Respiratory disorders
10. Allergies--tendency to asthma
11. Brown spots or bronzing of skin
12. Dizziness when quickly rising
13. Osteoarthritis
14. Low blood pressure
15. Small scanty eyebrows
Hyperovary : Female Only - Group 11 A
1. Increased sexual desire
2. Genitals enlarged
3. Temperamental
4. History of pelvic inflammatory disease
 
5. Digestive problems
6. History of ovarian tumors
7. Periods started early before age 12
8. Prolonged period
Hypoovary : Female Only - Group 11 B
1. Ovarian cysts
2. Temperamental
3. Premature menopause
4. Acne
5. Digestive problems
6. Get colds at periods
7. Nervous
8. Depressed at periods
9. Little or no breast development
 
10. Increased weight in thigh area
11. Painful periods
12. Menopause
13. Period stopped (not due to menopause)
14. Light 'flow' during period
15. Hot flashes
16. Ovaries removed
17. Decreased sexual desire
Female Only - Group 11 C
1. Vaginal discharge
2. Menses scanty or missed
3. Painful breasts
4. Menstruation excessive and prolonged
5. Depression of long standing
6. Depressed feelings before menstruation
7. Painful menses
8. Menopausal hot flashes
 
9. Very easily fatigued
10. Acne worse at menses
11. Menstruate too frequently
12. Premenstrual tension
13. Hysterectomy/ovaries removed
14. Osteoporosis
15. Frequent yeast infections
Hypergonad : Male Only - Group 12 A
1. Irritable
2. Excessive growth of hair
3. Strong sex drive
4. Emotions aren't stable
5. Hungry most of the time
 
6. History of allergic skin problems
7. Excessive perspiration
8. Puberty before age 10
9. Testicle(s) enlarged
Hypogonad : Male Only - Group 12 B
1. Absence of hair growth
2. Arthritis
3. Hands feet cold & clammy
4. Male menopause
5. Painful sex
6. Fat--mainly of butt breasts and abdomen
7. Low or no sperm count
8. High pitched voice
9. Have to urinate at night
10. Irritable
11. Urine 'dribbling'
 
12. High blood pressure
13. Constipation
14. Leg pains
15. Soft pale delicate skin
16. Low back pain
17. Lack of appetite
18. Breast area enlarged
19. Stiff joints
20. Testicles not descending
21. Light or no beard
22. Depressed
Male Only - Group 12 C
1. Diminished sex drive
2. Urination difficult or 'dribbling'
3. Prostate enlargement
4. Lack of energy
5. Leg nervousness at night
6. Pain on inside of legs or heels
7. Depression
8. Migrating aches and pains
 
9. Avoid activity
10. Night urination frequent
11. Tire too easily
12. Frequent urination
13. Prostate trouble
14. Feeling of incomplete bowel evacuation
15. Prostitis
Neurotrasmitters - Group 13
1. Chronic pain
2. PMS
3. Apathy/Lethargy
4. Self Injury
5. Bipolar
6. Compulsivity
7. Insomnia
8. Obesity/Overweight
9. Fibromyalgia
10. Anxiety
 
11. Depression
12. Impulsivity
13. Sense of despair
14. Myoclonus
15. Aggression
16. Mood swings
17. Irritable bowel
18. Migraine Headaches
19. Panic attacks
Ear/Nose/Throat - Group 14
1. Sneezing attacks
2. Sinus problems
3. Drainage from ears
4. Hay fever
5. Stuffy nose
6. Hearing loss
7. Earaches ear infections
 
8. Ringing in ears
9. Itchy ears
10. Excessive mucous
11. Canker sores
12. Swollen or discolored tongue gums lips
13. Gagging frequent need to clear throat
Lungs - Group 15
1. History of emphysema
2. Shortness of breath
3. Asthma bronchitis
 
4. Chronic coughing
5. Difficulty breathing
6. Chest congestion
Mind - Group 16
1. Difficulty making decisions
2. Slurred speech
3. Stuttering stammering
4. Learning disabilities
 
5. Poor memory
6. Poor concentration
7. Confusion
8. Poor coordination
Skin - Group 17
1. Excessive sweating
2. Hair loss
3. Psoriasis
4. Hives or rashes
 
5. Eczema
6. Acne
7. Flushing
8. Dry skin
Eyes - Group 18
1. Glaucoma
2. Dark circles under eyes
3. Tunnel vision
4. Macular degeneration
 
5. Watery itchy eyes
6. Blurred vision
7. Cataracts
8. Swollen reddened or sticky eyelids
Weight Loss - Group 19
1. Shortness of breath
2. Excessive weight
3. Craving certain foods
4. Water retention
5. Compulsive eating
6. Binge eating/drinking
7. Difficulty losing weight
 
8. Excess wt. ALL over the body
9. Excess weight in neck, shoulders & arms ONLY
10. Excess weight in chest & stomach ONLY
11. Excess weight in the stomach ONLY
12. Excess weight in the hips & legs ONLY
13. Diabetes
Joints - Group 20
1. Pains aches in muscles
2. Recurrent backaches
3. Rheumatoid arthritis
4. Osteoarthritis
 
5. Pains or aches in joints
6. Feeling of weakness or tiredness
7. Stiffness or limited movement
Food Choices
Do you commonly eat late in the evening?
Do you consume 'junk' foods and 'junk' snacks regularly?
Do you consume ?red? meat (beef pork lamb venison etc.) more than 3 times per week?
Do you consume less than one cup of raw vegetables and one cup of raw fruits daily?
Do you consume more than 4 cups of dairy milk per week?
Do you cook some of your food in a microwave oven?
Do you drink beverages with meals?
Do you drink more than 2 cans of soda pop per week?
Do you eat less than 3 servings per week of whole grain foods (whole wheat bread brown rice oatmeal barley ect.)?
Do you eat more than 3 servings a week of white flour products (white bread rolls pasta etc.)?
Do you eat more than 4 servings of cheese yogurt sour cream and/or ice cream per week?
Do you eat processed meats (wieners sausage pepperoni baloney etc.)?
Do you eat products made from soybeans more than once per week?
Do you eat sugar candy ice cream baked goodies etc.?
Do you often consume items with NutraSweetTM or AspertameTM in them?
Do you regularly consume more than one of these foods in the same meal: meat fish cheese eggs cereal bread pasta rice fruit/fruit juice sweets?
Do you skip breakfast?
Do you snack between meals and/or in the evening?
Do you try to eat a concentrated protein food (meat fish milk cheese eggs nuts seeds) at every meal?
Do you use salt or salted foods?
When you eat a meal do you eat until you are stuffed?
Please list your 4 main health concerns in order of thier priority:
1. 2.
3. 4.
Your Contact Information
First Name*: A value is required.
Last Name*: A value is required.
Address*: A value is required.
City, State, Zip*: A value is required. Please select an item. A value is required.
Email Address*: A value is required.Invalid email format.
Phone*: A value is required.
Date of Birth*: A value is required.

If the results of your questionnaire require us to contact you, what’s the best time call you?*

  Please select a time.

Please note any other health conditions or diseases that you are aware of
which may not have been mentioned in the Toxicity Questionnaire:

 


DISCLAIMER (Please Read) :

The educational information offered in the How Toxic Are You Questionnaire is based solely on the indications provided by the client in their responses to the questions. The How Toxic Are You Questionnaire Report is not a medical diagnosis. The information provided is drawn from several Doctors with more than 30 years of experience in the natural health field. This information is not a substitute for consulting a qualified health care practitioner. The client is advised to make use of the How Toxic Are You Questionnaire Report judiciously on their own responsibility. There is no warranty regarding the results of using this information, and the author and publisher disclaim any liability for the actions of the client. These statements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure or prevent any disease. Nutritional advice, dietary supplements or other products are not offered to diagnose or prescribe for medical or psychological conditions nor to claim to prevent, treat, mitigate or cure such conditions, nor to recommend specific nutritional products as treatment of disease or to provide diagnosis, care, treatment or rehabilitation of individuals, or apply medical, mental health or human development principles. Your How Toxic Are You Questionnaire and personal information will be forwarded to us. We will be processing it and will respond with your How Toxic Are You Questionnaire Report soon. So, keep checking your email for your exclusive confidential report. This is NOT a physician to patient service. If you are ready to submit your responses, other information, and have read and understand the above disclaimer, CLICK ON the "SUBMIT" button now.


Please agree to terms. I Agree *


*Spam Image Verification: Please type the two words you see in the box below

 

 
The Website Center

Iceberg a Model of Dis-ease | Most Common Warning Signs of Toxicity | Toxins = Dis-ease | Toxicity Questionnaire & Disclaimer | Dr. Martin's Bio. | Contact Us

2004 NutritionWellnessCenter.com All Rights Reserved.