ADVANCED CLINICAL NUTRITION - Dr. D. Smith (940) 761-4045 Welcome to our secure Client website! | Our Cell-Friendly Visitor website is: AdvancedClinicalNutrition.Com - Dr. Smith Has Over 90% National and International Client Health Success Record!

1-HOME

2-INQUIRY QUESTIONNAIRE

3-CONTACT & COMPANY INFO

A-ABOUT DR. SMITH

B-COMPANY INFORMATION

C-SECURE CARD PROCESSING

D-INSURANCE CLAIMS

4-FAQ & LINKS

A-YES! WE CAN HELP YOU!!

C-AUDIO INTRODUCTION

5-WHAT OUR CLIENTS SAY

6-FREE SERVICES & MORE!

7-NEWSLETTER / SUBSCRIBE

A-ABOUT FREE EVALUATIONS

B-NEWSLETTERS 2014 to Now

C-NEWSLETTERS Prior 2013

8-SEMINAR & EVENTS

A-EVENT SCHEDULE

B-CHRISTMAS MAGIC - NOV

C-SECRETS TO HEALING-JULY

D-ABOUT ON-SITE TESTING

E-BCA REPORT-HOW TO READ

F-PUBLIC SPEAKING WEBPAGE

G-LECTURE REQUEST FORM

9-ARTICLES BY DR. SMITH

A-LIBRARY OF ARTICLES

B-VILLAGER PUBLICATIONS

C-WF PARENT PUBLICATIONS

10-EDUCATION - FREE & FEE

A-BLOG, FACEBOOK,TWITTER

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C-ELECTRO-MAGNETIC (EMF)

D-YOUTUBES-COMA, HAIR, WT

E-YOUTUBES-FAT FALLACY

F-MENTAL HEALTH

11-E-BOOKS BY DR. SMITH

12-OUR SERVICES

A-ONLINE/BY-MAIL SERVICES

B-NUTRITIONAL ANALYSIS

C-NUTRITIONAL CARE

D-SPECIAL SUPPORT PROGRAM

E-DIETARY ANALYSIS

F-THERAPEUTIC VITAMINS

G-PERSONAL EDUCATION(PEP)

H-FULLBODY DETOX OVERVIEW

13-WHY TEST?

A-TEST/EVALUATION DEFINED

B-POOR HEALTH COSTS!

C-NUTRITION SAVES & PAYS!

D-HESITATING TO ORDER?

14-LABORATORY TESTING

A-HAC SYMPTOMS REPORT

B-BLOOD CHEMISTRY-44TESTS

C-THYROID TESTS-BLD/HAIR

D-HAIR MINERAL TESTS

E-SALIVA HORMONE-ADRENALS

F-SALIVA HORMONE - FEMALE

G-SALIVA HORMONE - MALE

H-URINE - (BONE TESTING)

I-STOOL / DIGESTION TEST

15-SELF-THERAPY PROGRAM

A1-FIRST EVALUATION

A2-RE-EVALUATIONS

B-SUPPLEMENT INSTRUCTIONS

C-DIETARY EDU & COOKBOOK

D-ARTICLES

E-ACUTE SYMPTOMS

F-DOUBLE HELIX WATER

G-AIR & WATER PURIFIERS

16-19 SUBSCRIBER PAGES

17-NUTRITION EDUCATION

A-FEEL BETTER 3-6 WEEKS!

B-BODY BY DESIGN

C-YOU CAN HEAL YOURSELF!

D-NOT TOO LATE TO HEAL!

E-DISEASES R DEFICIENCIES

F-DIET IS NOT NUTRITION

G-NUTRITION CONFUSING?

H-TRUE WORK SITE WELLNESS

18-EVALUATION FORMS

A-DIETARY QUESTIONNAIRE

B-SUPPLEMENT QUESTIONAIRE

C-TOXICITY QUESTIONNAIRE

D-STRESS OPINIONNAIRE

19-EVALUATION ANSWERS

A-DIET EVALUATION

B-SUPPLEMENT EVALUATION

C-TOXICITY EVALUATION

D-STRESS EVALUATION

20-33 CLIENT WEBPAGES

FREE INITIAL CONSULTATION

21-NEW CLIENT INSTRUCTION

A - INFORMED CONSENTS-CPA

B - QUESTIONNAIRES

C - CLIENT ORIENTATION

D - INSURANCE CODES

22-RETESTING INSTRUCTION

23-SPECIMEN INSTRUCTIONS

A-BLOOD TESTS FROM M.D.

B-URINALYSIS TEST STRIPS

24-REPORT OF FINDINGS

A-BLOOD TESTING

B-HAIR TESTING

C-SALIVA & STOOL TESTING

D-BONE RESORPTION URINE

E-URINALYSIS

F-NUTRITIONAL EVALUATIONS

25-PEP BINDER DOCUMENTS

26-CLIENT CONSULTS & PEP

1-FIRST PROGRESS REPORT

2-WHERE AGING FAST BEGINS

3-pH BALANCING

4-BREATHING & RELAXING

5-SLEEP HYGIENE

6-FOOD INTRO RESPONSE

7-NUTRIENT GUIDES

8-METABOLIC ANALYSIS

9-ORGAN & GLAND HEALTH

10-LOVE TO LOSE WEIGHT

11-LOVE TO GAIN WEIGHT

12-LOVE 2 KEEP MY WEIGHT

13-MENTAL HEALTH FEEL JOY

14-CANCER PREVENTION

15-HEALTH MAINTENANCE

27-FORM & QUESTIONNAIRES

28-POLICIES & PROCEDURES

29-EQUIPMENT-AIR-WATER

A-DOUBLE HELIX WATER-DHW

B-PURIFIERS - AIR / WATER

C-CHI MACHINE-ALIGN SPINE

D-SAUNA (FIR & PORTABLE)

E-POWER EYES

30-PEP ADVANCED PROGRAMS

A-HEALTH CHEST EDUCATION

B1-DIETARY PLANS

B2-DIETARY PRINCIPLES

C-LIFESTYLE COACHING

D-MIND & BODY CONNECTION

E-ANATOMY DIAGRAMS

31-SPECIALIZED PROGRAMS

A-PERSONAL CARE PROGRAM

B-DENTAL HEALTH PROGRAM

C-DYSBIOSIS PROGRAM

D-FULL BODY DETOX PROGRAM

E-SCAR DETOXIFICATION

F-SPORTS NUTRITION PROG

32-SPECIAL WEBSITE LINKS

A-HERBS (BULK & ORGANIC)

B-FOOD PRESERVATION BAGS

C-HOUSEHOLD PRODUCTS

D-LINENS-NATURAL FIBER

33-CLOSURE PROCEDURES

A-KEY 2 MAINTAIN RESULTS

Want Results? Stop Taking The Wrong Vitamins! Best To Test Before You Buy!

 
 

FORMS AND QUESTIONNAIRES



 
 
 
A

 


ADRENAL FATIGUE QUICK CHECK

Document
1 Page
 
 


AXILLARY TEMPERATURE TEST (ATT)
 ARTICLE & CHART

Basal Metabolism Testing for 
Hypothyroid Function Analysis 

You may print the entire article or only the last page.  The last page is the Axillary Temperature Chart.  Please read the entire article for temperature testing instructions and how to record your temperature on this chart.

Document
1 Page
 
 
B


BLOOD PRESSURE & PULSE RECORD and CHART

  • Blood Pressure and Pulse Chart:
    • Provdes the normal readings according to your age.  These numbers represent the maximum numbers for healthy readings, which may differ from medical normal readings per age.
    • Find the numbers for Blood Pressure (Systolic and Diastolic) and Pulse for your current age and transfer this information where indicated on your printed copy of the "Blood Pressure and Pulse Record."  Remember to change these numbers when your age changes each decade.
  • Blood Pressure and Pulse Record:  This form is used to record blood pressure and pulse reading when you are currently receiving Clinical Nutrition Therapy to assist the body in normalizing blood pressure, when specially requested by Dr. Smith, and for preventative purposes.  Dr. Smith will verbally recommend or include on your Therapeutic Supplement Program of Care (POC) document how often to take your blood pressure and pulse.  Other instructions are included on this record form.

Document
BP/P Record
Document
BP/P Chart By Age
 
 
C

 
 CLIENT COMMUNICATOR (CC)

Print #1 CC and #2 CC below if you have 21 Symptoms or less, 
or all three, if you have over 21 symptoms that bother you the most.


#1 CC (21 or Less Symptoms) - 1 Page#2 CC (Side 2) - 1 Page#3 CC (22 or More Symptoms) - 1 Page
 

HAVE 43 OR MORE SYMPTOMS FOR 
THE CLIENT COMMUNICATOR, 
PRINT #1 TO #3 ABOVE 
AND #4 PDF TO THE RIGHT?


Document
#4 CC PDF - 1 Page
 

CLIENT INFORMATION FORM (CIF)
Update to provide new contact information for client,
physician, chiropractor and/or other professionals or
any other information on this form.

Document
6 Pages
 
 
D

 
DIET ACTIVITY REPORT (DAR)

Document
1 Page
 
 
 
Document
Drug List - 1 Page
---
DRUG AND SUPPLEMENT LISTS
  • Print the Drug List to the left to update changes to current drugs you take or to record information about any newly prescribed drug.  

  • Print the Supplement List to the right regarding any supplements you take daily or weekly that are not dispensed through Dr. Smith.

Document
Supplement List - 1 Page
 
 
H

 

HEALTH APPRAISAL COMPREHENSIVE (HAC) 
SUMMARY BARGRAPH QUESTIONNAIRE

Document
6 Pages
 
 


HEALTH HISTORY FORM (HHF)



Document
4 Pages
 


HYPOTHYROID QUICK CHECK (HQC)

Document
1 Page
 
 
 
I

 
INFORMED CONSENTS


 INFORMED CONSENT - CLINICAL NUTRITION PROGRAM 
(IC-CNP) - [1 Page]


INFORMED CONSENT - BUSINESS POLICIES
(IC-BP) - [3 Pages]

Document
IC - CNP
INSTRUCTIONS
  
Please read, then USPS mail both signed original Informed Consents to
Dr. Smith, if you have not sent this since its last update
 and
keep a copy for your records.  
Date of last update in bottom right corner of each page.

Document
IC - BP
 
 
M



MULTIPLE APPOINTMENT REMINDER (MAR) FORM

Document
1 Page
 
 
O



OSTEOPOROSIS FRACTURE RISK ASSESSMENT QUESTIONNAIRE (2 Pages)

Document
OSTEO RISK
 
 
P



pH URINE AND SALIVA -  7-DAY TEST FORM 

Document
pH 7-Day Form
 
 
S


SCAR/TRAUMA CHART (1-Page)
(Open, Type, Print)


Document
STC
 

SPECIMEN KIT INSTRUCTIONS AND CHECK LISTS

  
  • Open PDF Icon to the right for instructions to prepare for, collect and mail Lab Kits and/or have blood drawn and 
  • to complete Health History and Symptoms Questionnaires, then fax, email or U.S. mail questionnaires to A.C.N. 

Document
Print Checklist For Lab Testing
 
 
STRESS ASSESS QUESTIONNAIRE (1-Page)



Document
STRESS ASSESS
 

SUCCESS STORIES FORM

Please complete this on each symptom or health challenge, or the ones you are most inspired to report on, that has benefited from our clinical nutrition therapeutic services... so that:
  • we may have narrative feedback about your health improvement for our records.
  • we may share your success with others so they may be encouraged that Clinical Nutrition and Naturopathic Therapy Really Works!!!  Remember when you first became a client and was unsure about clinical nutrition therapy.  Your success story can be that deciding factor to give someone else the confidence to give clinical nutrition a chance to prove to them, too, that it works.
Thank you for sharing.

Document
SSF
 

SYMPTOM SURVEY FORM (SSF)
(2 Pages)

Document
SSF
 
 
U

 

URINALYSIS TEST STRIPS - RECORD (1-Pages)
Record monthly urine test results on this document and submit a copy of the updated record the day
before each Progress Reporting (PR) and Report of Finding (RF) Consultation Appointment. 

Document
UT RECORD
 
 
 
W

 

WEBPAGE PASSCODE LOG

Updated as of 05/02/22

If you did not print this from your Welcome Email, please do this now.  
Record all passcodes in the appropriate places on this log and
 keep it in front of Index Tab #1 of your 
Personal Education Program (PEP) Binder for quick access. 

Document
Passcode Log - 1 Page
 
 
 
FOOTNOTE
Secure Website Info - Disclaimer - Copyright

Last Website Update: 05/25/22  5 p.m. CST

Disclaimer:  Information provided in website for nutritional educational purposes only 
and not for diagnosis or treatment of any medical condition, disorder or disease
.
MAILING ADDRESS:  P. O. BOX 4652, WICHITA FALLS, TX 76308-0652
Copyright 2004  Dr. Donna F. Smith   All Rights Reserved
  .NET 8/22/18

You may have noticed Google is now placing a padlock icon to the left of some website addresses as an attempt to designate "secure" vs. "unsecure" website.  They are particularly interested in adding padlocks to website to assure the public that websites with shopping carts are secure for financial transactions, and not so much as a way to say the website is free of malware.  

Our website does not have a shopping cart because it is what is termed an "information only" website.  So our website has no need for a padlock.  Regardless of the reason, they are unable to add the padlock to our secure website because it is an older web design from the 1990's.  Therefore, no matter what warnings they may give you, rest assured that this website is secure.

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