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