Nutritional Survey

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Nutritional Survey

An impartial nutritional supplement recommendation will be sent out to you including any advice necessary to help you improve your health and vitality. If you are concerned that your condition requires professional help then please see the section below where you can request help from a qualified doctor.

Name:			Date:
Email:			Gender: Age:

What best fits you
(please tick boxes that apply)

Actor	Dancer	Executive
Pregnant/Nursing Mother	Runner/Jogger	Lorry/Truck Driver
TV Junkie	Night Shift Worker	Over 60
Sports Person	Teacher	Drink Alcohol
Medical Profession	Truck Driver	High Stress Job
Builder	Handicapped	Tennis Player
Smoker	Student	Drug Taker (medical or street)

General Symptoms
(please tick boxes that apply)

  Abcess   Appetite Loss   Athlete's Foot

  Bad Breath   Bedsores   Body Odour

  Broken/Fractured Bones   Bruises   Cellulite

  Cold Feet   Colds   Dandruff

  Diarrhoea   Ear Noises   Haeomorrhoids

  Hangovers   Headaches/Migraine   Heartburn

  Infections/Colds   Joint Problems   Loss of Smell

  Monopause   Motion Sickness   Muscle Soreness

  Overweight   Prostrate Problems   Skin Problems

  Sunburn   Underweight   Varicose Veins

  Water Retension   Allergies   Asthma

  Backache   Bad Circulation   Bleeding Gums

  Boils   Bronchitis   Candida Albicans

  Cholesterol (High)   Cold Sores   Constipation

  Depression   Dizziness   Fatigue

  Hair Problems   Hay Fever   Heart Palpatations

  High Blood Pressure   Itching   Leg Pains

  Memory Loss   Menstural Cramps   Nervousness

  Post Operative Healing   Retarded Growth   Stress

  Tremors   Vaginal Itching   Warts

  White Spots on Nails

What vitamin or supplement are you taking currently? Are there any other conditions you would like to mention? Are you currently under medical supervision?

Are you taking any medication - if so what?

Complete this section if you would like your case to be reviewed by Dr Josef Kees MD
(please tick all the boxes)

I have symtoms of an illness, ailment or condition that needs professional help.
I am intersted in addressing my condition through causative, restorative and regenerative therapy.
I am aware that Dr Josef Kees is a private practitioner.
Dr Kees is a private practitioner and not available through the NHS

   Please keep me informed about Natural Health issues and offers.

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