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Professional Consultants

DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com


The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

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Clinical and Sports Nutrition Analysis Questionnaires

Client Information

Dietary History Questionnaire

Exercise and Athletic Training Questionnaire*

Feminine Health Appraisal Questionnaire
Health Appraisal - Comprehensive*
Metabolic Appraisal Questionnaire*
Symptom Survey Form*
Informed Consent
     Special Note: Click BACK and PRINT the Anthropometric Questionnaire. After completing the exercises, list the anthropometric results in the spaces provided on the Exercise and Athletic Training Questionnaire.

Re-Evaluation Analysis:
    Complete only the above questionnaires with an asterik (*) when ordering your Clinical and Sports Nutrition Comprehensive Re-Evaluation Analysis.