Nutritional Questionnaire

Take this Free Online questionnaire to see if you are a candidate for Nutritional Support.

We often forget the problems that are bothering us. Please supply you’re contact information and check each box in which the conditions apply to you.

Please List Any Allergies You Suffer From:

Please Indicate Your Blood Pressure Level:

Please Indicate Your Cholesterol Level:

If you suffer from Chronic Colds/Flu/Sinus/Bronchitis, etc.
Please list ailment and how often:

If You Suffer From Headaches and Migraines, how often:

If You Suffer From Sore Throats and Earaches, how often:

Rate Your Level of Fatigue/Low Energy/Chronic Fatigue Syndrome:
0 1 2 3 4 5 6 7 8 9 10

Rate Your Level of Stress - difficutly handling it:
0 1 2 3 4 5 6 7 8 9 10

When these symptoms are relieved, would that change your life?
Yes No Maybe

What is the best time of day for Dr. Kearns to contact you for a complimentary 10 minute phone consultation?

Phone Number:

Aching joints
Asthma/Shortness of Breath/Lung Disease

Back Ache pain/Neck Ache pain
Bleeding Gums/Canker Sores/Cold Sores
Carpal Tunnel Syndrome
Poor Concentration
Constipation or Irregularities
Cravings - Chocolates, Sweets, Caffeine, Snacks, etc.
Cuts/Bruises - Heal Slowly
Depression or Anxiety
Diabetes/Blood Sugar Fluctuation
Difficulty Falling Asleep/Insomnia
Difficulty Getting Up In The Morning
Digestive Problems/Heart Burn/Irritable Bowel
Eat Junk or Fast Food Frequently
Fibromyalgia/Muscle Pain
Hair Loss/Dull Hair
Hypoglycemia/Low Blood Sugar
Menopause/PMS/Mood Swings/Hot Flashes
MS/Lupus/Lyme Disease
Muscle Cramps
Skin or Nail Problems/Psoriasis/Eczema/Rosecea
Tingling in Feet or Hands
Ulcers or Indigestion