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FORMS AND QUESTIONNAIRES - ALL
Before Reading This Page, Please Read the "Forms & Questionnaires" web page.
This web page lists all General Client Forms. If the form you seek is not listed below, you will find the form on either the "PEP Binder Documents," "Specialized Program" or "PEP Lifestyle Program" Web page, whichever applies.
AXILLARY TEMPERATURE TEST This document has not been updated to remove the instructions at the bottom of the form that reads to bring this form to your next appointment. Instead, after you have completed your 10-day temperature test as instructed on this form, email it to Dr. Smith the day before your next Progress Reporting (PR) or Report of Findings (RF) appointment, whichever comes first. Please excuse the rough appearance of the form, a more clear copy of this form will be posted in its place at some point in the future.
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.
Open PDF Icon Documents in the right column, which apply to you:
If this is your first Client Communicator to print for recording on and
You have less than 21 symptoms, print "CC - Page 1 - Symptoms 1-21."
If you have more than 21 symptoms, print "CC - Page 1 - Symptoms 1-21" and "CC - Page
2 - Symptoms 21-42."
If you have completely each column in your current Client Communicator, print the PDF document titled, "Side 1 - No Numbers" below, Then hand-write in the first column on Side 1 the next number that follows according to the last number for the row on the Client Communicator you just completed. Where indicated in the upper-right corner, hand-write the page number on Side 1.
For example if you have completed "CC - Page 1 - Symptoms 1-21" because you had 21 or less symptoms, then this would be page 2.
However, if you had 42 or less symptoms, then this would be page 3.
Print "CC - Side 2 for Page 1 & 2 and Side 1" on the back of all of the above.
If you are printing this because your previous Client Communicator form is full, please transfer symptoms from your previous CC to your newly printed CC form, unless you have a zero (0) score for three months in a row.
Update the Client Communicator before each Progress Reporting (PR) Consultation and send to Dr. Smith by fax, email or U.S. so that it arrives at least 48-hour before PR appointment.
Update the CC form before each Report of Findings Consultations, unless it has already been updated at a Progress Reporting Consultation scheduled in the same month.
Read instructions on Page 2 and include updates as they occur.
HAVE 43 OR MORE SYMPTOMS FOR THE CLIENT COMMUNICATOR? Use the "CC-PAGE 1 - NO NUMBERS" - PDF DOCUMENT AT RIGHT
After completing CC - Page 1 and 2 above, print PDF document for "CC - Side 1 - No Numbers if you have more than 42 Symptoms to record on the Client Communicator. This form has no numbers in the left column so you can insert the numbers, accordingly. Then on the back of each additional CC-Page 1 - No Numbers" form, print the above "CC - Side 2 for Page 1" - the same Side 2 page you printed on the back of CC - Page 1 (#1 - 21) and CC - Page 2 (#22 to 42).
CLIENT INFORMATION FORM (6-Pages) Update to provide new contact information for client, physician, chiropractor and/or other professionals or any other information on this form.
Please open, print, complete, send via fax, U.S. mail or email to regarding new or update drug information (name, type, dosage, frequency, duration, etc.
If you did not complete this form with your initial Health and Symptom Questionnaires when you first became a client, please complete every question that applies to you as instructed on this form. For Re-Evaluations, you may complete only the questions that need to be updated since the initial completion of this 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.
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.
Print this log and keep it in a safe place. As you receive services that include passcodes to open other web pages for educational information and forms, write them in the appropriate place on this log.
These passcodes will be included on your invoice provided for payment of these services. Otherwise, they may be communicated verbally at the consultation when education is presented or sent in an email.
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: August 25, 2014
