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.
Name:

     
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:
                   
Email:
 

Aching joints
Asthma/Shortness of Breath/Lung Disease

ADD/ADHD
Back Ache pain/Neck Ache pain
Bleeding Gums/Canker Sores/Cold Sores
Cancer
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
Diverticulitis/Colitis/Hemmoroids
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
Overweight/Underweight
Skin or Nail Problems/Psoriasis/Eczema/Rosecea
Tingling in Feet or Hands
Ulcers or Indigestion