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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

Women Sports Nutrition Logo
Food Chemistry Plan Adherence Report (FCPAR)

PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:


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

Copyright 1999 Donna F. Smith

Please indicate with a number from 0-10 your level of adherence to your Food Chemistry Plan (0=no adherence to 10=followed program precisely as directed every day since last report)

Instructions below:
Date:
Water Intake per my body weight in quarts
Morning Lemon Water
Ate Acceptable Foods
Ate Moderate Foods
Eliminate Avoid Foods
Additional Avoid Foods
Supplements as directed
Ate Breakfast
Morning Snack
Ate Lunch
Energy Drink 1-2 p.m.
Afternoon Snack
Ate Dinner/Supper
Dinner Lemon Water
Followed all Do Have's
Avoided Do Not Have's
Number Recipes Used
Eating when Calm
FCP Pattern

KEY: Score of 9-10 = healing occurring; 8 = maintenance; 7 or lower = dietary deficiency

In the box to the right of FCP Pattern, put the number of your Food Chemistry Specific Dietary Plan.

Copyright, 1999 Donna F. Smith