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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 Information
ALL ITEMS MUST BE COMPLETED.

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.

PERSONAL DATA:
Name: (First, middle, last name) Date Complete Form: / /
Address: E-mail Address:
City: Home Phone: ( ) -
Day Night
State: Zip Code: Work Phone: ( ) -
Day Night
Sex: M F Age:
Date of Birth: / / 		Fax: ( ) -
Referred by: Marital Status:
Sitting Blood Pressure: / Spouse's Name:
Height: Weight: lbs.


IF CLIENT IS A CHILD, COMPLETE THE FOLLOWING:

Mother's Name: Father's Name:
Mother's Occupation: Father's Occupation:
Employed by: Employed by:
Phone No.:( ) - Phone No.:( ) -
Marital status of parents: Child lives with:
Current Grade: Age when entered school:

EMPLOYMENT DATA:

Occupation: Employed by:
Work Hours: Day Night
If you sleep during the day, please list best time of day to receive calls: 		Do you work with chemicals, metals or
any other pollutant? Yes No
If Yes, list them:
Can you receive calls at work?
Yes No 		Place of employment:

BILLING AND MAILING INFORMATION:
Name of person responsible for bill: Mailing address if different from home: (UPS WILL NOT DELIVER TO P.O. BOX)
Address: Address:
City: City:
State: Zip Code: State: Zip Code:
Is this person current client:
Yes No 		Is this address a business or residence ?

NUTRITIONAL SUPPLEMENT DATA:

List vitamins, minerals, herbs, etc. you are currently taking: Include dosage, frequency, and how long you have taken them. List brand names and where you purchase vitamins, minerals, etc.:
1. 1.

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4. 4.
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6. 6.
Vitamins, herbs, etc., allergic to:
  

MEDICAL DATA:

Name of personal physician: Number of years seen by physician:
Address: Physician's Specialty:
City: Office Phone:( ) -
State: Zip Code: Emergency Phone:( ) -
List current medications: dosage, frequency, time of day, length of time on medicines and reason for taking: Prescribing physician: name and office phone number, along with physician's specialty:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
If need more space, send additioanl info through email address: wsnorder@aol.com Medicines allergic to:

CHIROPRACTIC DATA:

Chiropractor: Office Phone No.:( ) -
Address: Date of last adjustment:
City:
State:     Zip Code: 		Reason for treatment:

SURGERIES:

Tonsils removed:
Yes     No     Year: 		Ovaries Removed:
Yes    No     Left     Right     Year:
Gall bladder removed:
Yes     No     Year: 		UTERUS REMOVED: Yes     No     Year:
Other:      Year: Other:     Year:

CURRENT SYMPTOMS - LIST IN ORDER OF MOST CONCERN:

LIST OF SYMPTOMS:
Also list area of body and any event surrounding the symptoms, such as injury, etc. On a scale of 0 to 10; 0 = no discomfort or pain and 10=severe pain, how would you rate your discomfort?		 FREQUENCY:
How often do you feel discomfort or pain: all day long, 2-3 times a week or month.		 DATE OF ONSET:
When did you first notice the symptom.		 IS SYMPTOM ASSOCIATED WITH A MEDICALLY DIAGNOSED DISEASE?
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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