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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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Dietary Analysis (DA) Questionnaires


     When ordering the Dietary Analysis (DA) separately from the Clinical and Sports Nutrition Comprehensive Analysis, complete the following questionnaires. The questionnaires with an asterisk (*) are to be completed and sent with only the first Dietary Analysis, unless otherwise instructed. In other words, after ordering your first Dietary Analysis, you need only complete the Metabolic Appraisal Questionnaire when re-ordering the Dietary Analysis for re-evaluations.
Metabolic Appraisal Questionnaire (MAQ)

Dietary History Questionnaire* - (Send with first order only)

Client Information* - (Send with first order only)

Informed Consent* - (Send with first order only)