HOME / FAQ LINKS

YES! WE CAN HELP YOU!!!

VIDEO INTRODUCTION-2, 10M

AUDIO INTRODUCTION-2, 40M

INQUIRY QUESTIONNAIRE

WHAT OUR CLIENTS SAY

CONTACT / ABOUT US

ABOUT THE COMPANY

ABOUT DR. SMITH

BIO - CURRICULUM VITAE

ORDERING W.F. SUPPLEMENTS

MILA - PLANT SOURE EFA

CASH BACK TO SHOP ONLINE

EMERGENCY HOT LINE

MENTAL HEALTH

NEWSLETTER / SUBSCRIBE

ABOUT FREE EVALUATIONS

NEWSLETTER PAST ISSUES

WHY TEST?

TESTS/EVALUATIONS DEFINED

POOR HEALTH COSTS!

NUTRITION SAVES & PAYS!

HESITATING TO ORDER?

LAB TESTS - INSURANCE?

HAC SYMPTOMS REPORT

BLOOD CHEMISTRY- 44 TESTS

THYROID BLOOD/HAIR TESTS

HAIR TISSUE MINERAL TESTS

SALIVA HORMONE - ADRENALS

SALIVA HORMONE - FEMALE

SALIVA HORMONE - MALE

URINE - (BONE TESTING)

STOOL/DIGESTION-PARASITES

OUR SERVICES

ONLINE & BY-MAIL SERVICES

NUTRITIONAL ANALYSIS

NUTRITIONAL CARE PROGRAMS

SPECIAL SUPPORT PROGRAMS

DIETARY ANALYSIS

THERAPEUTIC VITAMINS

PERSONAL EDUCATION (PEP)

ARTICLES BY DR. SMITH

LIBRARY OF ARTICLES

CALICUM IS NOT ENOUGH

COFFEE ARTICLE

SCARS & TATTOOS

SELFGROWTH.COM ARTICLES

SLIDES & VIDEOS

SLIDE SHOWS

COMA, HAIR, WEIGHT

FLU FALLACY, BEA'S STORY

CHI MACHINE-ALIGNS SPINE

E-POWER/KEY TO ANTI-AGING

REFLEXOLOGY MACHINE/TENS

HOT HOUSE (GERM DETOX)

SOQI BED / HOME SPA

WEIGHT LOSS 1 AND 2

BLOG, FACEBOOK, TWITTER

SEMINAR ANNOUNCEMENTS

JULY - SECRETS TO HEALING

NOVEMBER CHRISTMAS MAGIC

ABOUT ON-SITE TESTING

LECTURE REQUEST FORM

E-BOOKS BY DR. SMITH

QUESTIONNAIRE - SKIN CARE

ANTIAGING-SKIN,HAIR,NAILS

FIBROMYALGIA E-BOOK

HAIR RESTORATION PROGRAM

THANK YOU FOR ORDER

---SUBSCRIBER WEBPAGES---

NUTRITION EDUCATION

FEEL BETTER IN 3-6 WEEKS!

BODY BY DESIGN

YOU CAN HEAL YOURSELF!

IT'S NOT TOO LATE TO HEAL

DISEASES ARE DEFICIENCIES

DIET IS NOT NUTRITION

CONFUSED ABOUT NUTRITION?

TRUE WORK SITE WELLNESS

NUTRITION PROFESSIONALS

EVALUATION QUESTIONNAIRES

DIETARY QUESTIONNAIRE

SUPPLEMENTS QUESTIONNAIRE

TOXICITY QUESTIONNAIRE

STRESS OPINIONNAIRE

EVALUATION - ANSWERS

DIET EVALUATION

SUPPLEMENT EVALUATION

STRESS EVALUATION

TOXICITY EVALUATION

--CLIENT WEBPAGES BELOW--

NEW CLIENT INSTRUCTIONS

PEP BINDER DOCUMENTS

ANATOMY DIAGRAM & DEFINED

POLICIES & PROCEDURES

INSURANCE/CPT-ICD9 CODES

FORMS & QUESTIONNAIRES

ALL FORMS/QUESTIONNAIRES

PROGRESS REPORTING

RETESTING

SKIN CARE QUESTIONNAIRE

SPECIMEN COLLECTION INFO

ABOUT HAIR SAMPLING

FASTING INSTRUCTIONS

BLOOD TESTS LIST & DR LTR

pH BALANCING

SPECIAL WEBSITE LINKS

AUTO-CARE PRODUCTS

CELL / WIRELESS PROTECTOR

CLOTHING - NATURAL FIBERS

FOOD - ORGANIC/FREE RANGE

FOOD - ORGANIC JUICES

FOOD PRESERVATION -G BAGS

FOOD SOURCE - VITAMIN D

FOOD SOURCE - EFAs (MILA)

HERBS (BULK & ORGANIC)

HOUSE-LAWN-POOL PRODUCTS

LINENS/BED-NATURAL FIBER

PERSONAL CARE-TOOTHPASTE

PERSONAL CARE - SUNBLOCK

SHOWER/BOTTLE H2O FILTERS

PEP LIFESTYLE PROGRAM

HEALTH CHEST EDUCATION

LIFESTYLE COACHING

MIND & BODY CONNECTION

SPECIALIZED PROGRAMS

ANTI-AGING PROGRAM

DENTAL HEALTH PROGRAM

DIETARY PROGRAM

DYSBIOSIS PROGRAM

FULL BODY DETOX PROGRAM

SPORTS NUTRITION PROGRAM

GOOD STANDING PROCEDURES

THERAPY COMPLETED

MAINTENANCE PROGRAM

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

 
 
INQUIRY QUESTIONNAIRE
(Scroll Down Web Page for Questionnaire form)
    
and to Schedule

   
FREE INQUIRY TELEPHONE CONSULTATION



To Prepare for Telephone Consultation with Dr. Smith,
To  Inquire About and To Order
 
Clinical Nutrition Testing....


  • Please Read All the Information On This Web page.
  • Complete each question in the Inquiry Questionnaire below and then click the 'Send" button.
  • Read and following the instructions in "How To Prepare For Your Inquiry Telephone Consultation with Dr. Smith" and the Frequently Asked Questions At The Inquiry Consultation PDF Document, both of which are located after the Inquiry Questionnaire.
  • Attention Inquirers - please open and read the PDF File to the right before scheduling appointment with Dr. Smith.
  • After the above, you are ready to schedule your Free No-Obligation Inquiry Telephone Consultation With Dr. Smith by Calling the number below or you may wait for our office to call you, if you have provided the Best Days and Times (C.S.T.) to call you on the Inquiry Questionnaire.
  • Please allow 90 minutes for the Inquiry Consultation.  More time may be required, depending upon the number of questions asked OR less time, when the Inquirer and the Head of Household have read and completed the instructions on this web page and their PDF documents.

CONTACT INFORMATION


PURPOSE OF INQUIRY QUESTIONNAIRE

Reviewing the Patient's Personal Information on the Inquiry Questionnaire, before the Inquiry Telephone Consultation, will give Dr. Smith the opportunity to prepare an Initial Nutritional Assessment and Financial Plan so that she may recommend the specific services that best suits the patient's needs and will save time at the Inquiry Telephone Consultation. 

If the Inquirer is not the Head of Household, please read the "Attention Inquirers" PDF Document below and schedule the Inquiry Telephone Consultation with Dr. Smith when the Head of Household can be present with the Inquirer.  Note:  This includes the Patient, too, if the Patient is not the Inquirer  or a child under 12 years old.

Document
ATTENTION INQUIRERS
                                                                        __________________________________________________   

CONFIDENTIALITY
Information on the Inquiry Questionnaire is confidential and used only by Dr. Smith and her staff for the purpose of the Inquiry Consultation and providing the services of Advanced Clinical Nutrition.  You may click on the PDF Document below for our complete Confidentiality / Privacy Notice.  In the event, our clinical nutrition services are not engaged at this time, no future contact will be made to the Inquirer or Patient, if not the same, using the information on the Inquiry Questionnaire, unless requested by the Inquirer or Patient.  We respect your privacy.  

Note:  If clinical nutrition therapy is not started at this time, we highly recommend that you read he "W.F. Supplements" web page and order whole food supplements for health maintenance purposes as needed. T
aking synthetic and isolated vitamin and mineral supplements, which are the primary supplements sold to the public today, suppresses symptoms and manipulates your biochemistry, which in time leads to a myriad of new health challenges.  Only Whole Food  (W.F.) Supplements heal and maintain health.  The "W. F. Supplements" web page is located in the Table of Contents under the "Inquiry Questionnaire."

Dr. Donna F. Smith
(940) 761-4045

Services@AdvancedClinicalNutrition.com

Thank you.

Document
Privacy Notice
 
  
INQUIRY QUESTIONNAIRE

Provide Patient Information, Unless Otherwise Requested.

 
DATE COMPLETED INQUIRY QUESTIONNAIRE:
PATIENT'S FIRST & LAST NAME:
NOT PATIENT? YOUR FIRST/LAST NAME & RELATIONSHIP?
AGE:
BIRTHDATE:
E-MAIL ADDRESS:
WHO OR WHAT REFERRED YOU? IF INTERNET, PLEASE LIST KEY WORDS.
YOUR TIME ZONE? (NOTE: APPTS ARE SET IN C.S.T.)
BEST DAYS & TIMES (C.S.T.) TO CALL YOU?
DAYTIME PHONE NUMBER:() -
EVENING PHONE NUMBER:() -
FAX NUMBER:() -
MAILING ADDRESS:
CITY, STATE, ZIPCODE:
COUNTRY:
#1 HEALTH CONCERN?
#2 HEALTH CONCERN?
#3 HEALTH CONCERN?
#4 HEALTH CONCERN?
#5 HEALTH CONCERN?
OCCUPATION:
EXPOSED TO CHEMICALS OR METALS AT WORK OR HOME? IF YES, LIST.
DID YOU READ ALL "WHY TEST?" WEBPAGES? YES OR NO.
DID YOU READ ALL "OUR SERVICES" WEBPAGES? YES OR NO.
DID YOU READ THE "ORDERING W.F. SUPPLEMENTS" WEBPAGE? YES OR NO.
IF YOU ANSWERED NO TO READING WEBPAGES, PLEASE PUT EITHER "I WILL OR WILL NOT READ BEFORE APPT."
DID YOU SUBSCRIBE TO DR. SMITH'S NEWSLETTER? YES OR NO.
IF YOU HAVE NOT SUBSCRIBED, DO YOU PLAN TO? YES OR NO.
INTERESTED IN IMPROVING CONCERNS, OVERALL HEALTH, OR BOTH?
DO YOU HAVE THE FINAL WORD REGARDING FINANCES? (YES OR NO) PLEASE ANSWER ACCURATELY. IF ANSWER IS NO, HEAD OF HOUSEHOLD MUST BE PRESENT AT INQUIRY CONSULTATION.
FIRST/LAST NAME OF HEAD OF HOUSEHOLD:
IF YOU WERE REFERRED BY A PERSON WHO IS NOT A CLIENT, PLEASE PROVIDE THEIR ADDRESS SO WE MAY SEND THEM A THANK YOU CARD.
IS THERE ANYTHING ELSE YOU WANT TO COMMUNICATE TO DR. SMITH?
 

HOW TO PREPARE FOR YOUR INQUIRY
TELEPHONE CONSULTATION WITH DR. SMITH

 


It is important to Dr. Smith that you make an "informed" decision about starting clinical nutrition therapy.  To do this information has been provided on our website, which will also save time at your Inquiry Consultation with Dr. Smith and allow that time to be used to answer "personal" questions, as well as share the specific services and  their fees that apply to improving your health challenges. 

Therefore, once you have completed and sent your Inquiry Questionnaire, if you have not already read the following, please do so before your
Inquiry Telephone Consultation with Dr. Smith.  To build a foundation of knowledge, please read in the order presented.
  1. If you are not the Head of your Household or if all financial decisions are made with mutual agreement between both partners, read the "Attention Inquirers" PDF document in the upper-right corner of this web page.
  2. Then in this order, please read the following web pages, and the pop up web pages attached to them, when provided;
    • "Why Test?" - these web pages help you understand the difference between an evaluation and a test, as well as why testing is important, how clinical nutrition saves and pays you now and in the future, and gives you an overview of what poor health is costing you.
    • "Lab Tests - Insurance?" - The most frequently ordered Lab Tests are listed on this web page with a link to their individual web pages.  Questions about insurance coverage for our services is also answered on this web page.
    • "Our Services"  - all other services have their own web page here and answer questions regarding how our services are provided.
    • "Ordering W.F. Supplements" - this is an important web page for family and friends of our clients, and the Inquirer should you choose not to start clinical nutrition therapy after your Inquiry Consultation with Dr. Smith.
  3. Lastly, coming soon is a "Frequently Asked Questions" At the Inquiry Consultation PDF File, which will be posted below.
After completing the above, you are ready to schedule your appointment.  You may do one of the following:
  1. Call our office and if Dr. Smith is available, she will take your call and provide your Inquiry Consultation at that time.   if she is not available her assistant will schedule the appointment. 
  2. Wait for Dr. Smith to call you during the next available time in her schedule that aligns with the "Best  Days & C.S.T.  Times To Call You?" as indicated on your Inquiry Questionnaire.  
  3. If you are a female inquirer, please open and read the PDF File above the Inquiry Questionnaire, titled "Attention Female Inquirers."  .
Thank you for reading the above and completing each question on the Inquiry Questionnaire so you may save both yourself and Dr. Smith time at your Inquiry Telephone Telephone Consultation and so that you and the Head of your Household, if not the same, can make a truly informed decision about starting clinical nutrition therapy.

Completing the Inquiry Questionnaire will also help Dr. Smith prepare to answers questions to your satisfaction and select services specific to your needs
. 


 

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