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Symptom Survey Form

This online symptom survey program looks at your body systems and is an important part of our overall program to support your quest for better health .  The allopathic model looks at pathology and disease; we are looking at those signs and symptoms that are the indicators of overall health from a foundational model looking for the root cause of the problem. By carefully going through each question, you will give Joseph a clearer understanding of how to support your personal needs.

Instructions for the online survey:

1. Follow the instructions on the screen to create your personal login. Write your login information down for your revaluation.

2. After logging in to your new account, fill in as much information as possible, noting the required fields. Then press “Save”, then “Done”.

3. Accept the Disclosure Agreement.

4. Click on next to “Enter a new Symptom Survey” & continue.

5. Enter height, weight, and other vital signs like blood pressure and pulse if known - they help the program refine your personal support. Follow instructions to answer the questions.

6. Consider all questions; scroll down to see all of screen. Click “Next” when done with that group.

7. Click “Exit” when complete. Click “Save/Finish” if done or “Review/Edit” to make changes. 

Toxicity Questionnaire

This questionnaire will help Joseph to determine any potential need for a detoxification program, and any other supplements that can help support your body in better health. 

Weston A. Price Foundation

The Weston A. Price Foundation is your source for accurate information on nutrition and health, always aiming to provide the scientific validation of traditional foodways. People seeking health today often condemn certain food groups — such as grains, dairy foods, meat, salt, fat, sauces, sweets and nightshade vegetables — but the Wise Traditions Diet is inclusive, not exclusive.  WAPF show you how to include all these nourishing traditional foods in your diet through wise choices and proper preparation techniques. The result is vibrant health for every age of life, including the next generation.


Stratford Acupuncture & Nutritional Wellness Center
1000 Bridgeport Ave
Shelton, CT 06484
Phone: 959-600-6335
Fax: 203-345-9827

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