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STOP Taking The Wrong Vitamins! - It's Best To Test, Before You Buy..Vitamins!

 
 
EVALUATION REQUEST
FORM

 
   
INSTRUCTIONS

Upon receipt of your completed Evaluation Request Form for the Free Evaluation you have selected, you will be emailed passcodes to open its related Evaluation webpage.  The questionnaire is provided at the top of the Evaluation web page and we recommend that you open, print and complete the questionnaire before reading the Evaluation webpage.  Otherwise your answers may be influenced by the evaluation answers.   two questionnaires.  The Stress Opinionnaire and Toxicity Questionnaire have their own Request Forms.   

Each question on the Evaluation Request Form must be completed accurately and honestly to receive your passcodes.  Your personal information is confidential and contact information is requested only for the purpose of providing your Free Evaluation, unless you have also requested to schedule an Inquiry Consultation with Dr. Smith.  If after this consultation, you choose not to order a clinical nutrition analysis of your biochemistry at this time, your contact information will become inactive, i.e., not be used again.
   

Links To Each of The Four Free Evaluations in right column.

 
EVALUATION REQUEST FORM - PLEASE CAPITALIZE ALL ANSWERS. THANK YOU. Date:
First, Middle Initial, Last Name:
Birthdate
E-mail Address
Who or What Referred You to us? If internet search, please list keywords.
Cell Phone() -
Daytime Phone (Is this Home or Work#)() -
Evening Phone (Is this Home or Work#)() -
Best Days To Call (M-F)
Best Times of Day (C.S.T.)
Address Line 1
Address Line 2
City
State
Zip Code
Country
I am completing the DEO (Diet) Yes/No
I am completing the NSQ (Nutrient Supplements - Symptoms Warrant Supplementation (Yes/No)
I am completing the Stress Opinionnaire (Yes/No)
I am completing the Toxicity Questionnaire (Yes/No)
Do you want to schedule a Free Telephone Consultation with Dr. Smith to discuss the Evaluation Results? Yes, No, Maybe, Depends On The Results?
What prompted you to browse our website and what are you specifically wantinig help with or questions you want answered?
Are you interested in improving your overall health, starting with your most challenging health concerns, help with just your major health concerns, or a one-time nutritional support program to speed recovery of an acute illness or injury, or all of the above, as needed?
What is the approximate number of years you have been taking vitamins or other food supplements? Provide date or put "Never Taken."
Is there any other information Dr. Smith should know in assessing your Evaluation?
 
    
Success Record

   
We have over 90% success in assisting our clients in improving their health, no matter what their current health challenges.


 

Clientele
Our clientele encompasses
35 U.S. States and four
international countries
.

 


Four Free Evaluations
To Choose From...


  • Dietary Evaluation Overview (DEO)
  • Nutrient Supplement Questionnaire (NSQ)
  • Stress Opinionnaire (SO)
  • Toxicity Questionnaire (TQ). 

Click on the link above for information, instructions and to complete the EVALUATION REQUEST FORM  to receive Passcodes to open web page for the Questionnaire and Evaluation you have selected.

 

How To Obtain Additional Evaluations

You may choose one Evaluation for subscribing to Dr. Smith's HealthQuest e-News for a minimum of three months.  To obtain additional Evaluations, simply invite friends and family members to subscribe to our newsletter by emailing them a link to our website home page.   You may select one additional Evaluation for each referred subscriber.  One Evaluation per subscription and one subscription per household.

 
  
With Vitamin Deficiency Testing
    
Soon, you, too, will

  • improve your health,
  • increase energy,
  • manage weight,
  • control appetite,
  • balance hormones,
  • strengthen bones,
  • boost mental function,
  • regenerate cells,
  • heal tissue,
  • promote anti-aging, 
  • prevent disease, 
  • enhance life and sports performance,
just as thousands have done before you.

 
  
Click below
to inquire and order

     
a clinical nutrition analysis of the laboratory testing of your individual nutritional biochemistry
(blood, urine, saliva, hair, stool, etc.). 

From test results, Dr. Smith will design a personalized therapeutic, whole food (vitamin, mineral, herb, homeopathic) supplement and dietary program to meet your individual nutritional requirements.


TO INQUIRE and ORDER

 
Disclaimer/Copyright

Information provided in this website is for nutritional educational purposes only and not for the diagnosis or treatment of any medical condition, disorder or disease.
Copyright 2004  Dr. Donna F. Smith  --  Last Website Update:  January 16, 2012