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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
Client Communicator

Date:
Name:
E-Mail:

WSN Acct. No.:



     In the SYMPTOMS column below, list all current symptoms. In the SCORE column, put a number from 0-10 representing the degree of severity of your pain or discomfort. 10 means severe; 0 means no symptoms.
     The first time you were asked to report your Current Symptoms and Severity Score was on the Client Information Questionnaire. The symptoms and scoring on the Client Information Questionnaire represented the severity of your symptoms before you began your clinical and sports nutrition program. If you overlooked putting the score with the current symptoms on your Client Information Questionnaire, you may use this Client Communicator Questionnaire
to send this information. However, please indicate in the "Additional Information" box below that the symptoms and scoring represents those before starting your program with us.
     The Client Communicator is one of several questionnaires you will complete and send for your Monthly Progress Reporting. To complete the Client Communicator, simply transfer your list of CURRENT SYMPTOMS from the Client Information Questionnaire to the Client Communicator and provide a "severity" score for each symptom. The severity score on your first Client Communicator represents how you have felt from the time you began your program with us to today's reporting. Then one month later and each month thereafter, your score represents how you have felt since the date of the previous Client Communicator sent to us.
     If new symptoms appear after sending your Client Communicator, make a record of the new symptom and score, and then add this information to your next Client Communicator. If your new symptom's score is over 7, please e-mail or call us for additional help.
     Please make a copy of the Client Communicator before SENDING so that you have a record of the symptoms you will be scoring next month.

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Additional information on above symptoms, new symptoms or visits to other health professionals:
Please use the following space to provide additional information regarding the symptoms listed in the Symptoms List. First but the date you are recording, then the Reference No. of the Symptom , which is located to the left of the symptom on the Symptom List. When adding a new symptom to the Symptoms List, please provide details below, including when the symptom first occurred and how often you experience it. If a symptom has come and gone since your last visit, provide details about your experience below. Indicate below how many hours, days or weeks, etc. you suffered before it left, and indicate the date of onset and the date if left. Also use this space to provide information regarding any visit to another health care professional since your last visit here. Provide dates, reason for visit, diagnosis, treatment or medications prescribed, date of return visit and whether you have had any accidents since the date of the last reporting.



Copyright, 1999 Donna F. Smith