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

 
     
Toxicity Questionnaire

Is Your Health Adversely Affected By Daily Exposures to and
Ingestion of Toxic Substances from your Air, Food and Water,
e.g., chemicals, metals, fumes, fiberglass, to name a few?



 


INSTRUCTIONS
    
To Complete Your "FREE" Evaluation

  1. To show our appreciation and to say "Thank You" for subscribing, Dr. Smith offers your choice of one of four FREE EVALUATIONS.  Refer to right column for List of Free Evaluations and link to their web pages, as well as information on obtaining additional FREE EVALUATIONS. 
  2. To obtain the Toxicity Questionnaire (TQ), please complete the  "Evaluation Request Form." below.  This information is confidential and the questions asked either assist us with processing your Questionnaire for Evaluation or help us with demographic and marketing information.   Each question must be answered on the Request Form to receive your selected evaluation questionnaire. .
  3. Your personal contact information on this Request Form will only be used as it relates to processing your questionnaire and Evaluation, unless you, otherwise, indicate on this form.
  4. Upon receipt of your Evaluation Request Form, you will be emailed to you within 1-7 days with the User's Name and Password to access the web page titled, "EVALUATION - TOXICITY"  so you may print its questionnaire, obtain the assessment (or evaluation) of your answers and Dr. Smith's recommendations. 
  5. Important Note:  When you open the Evaluation web page, immediately click on the PDF Icon to print your questionnaire.  Then complete your questionnaire before reading the Evaluation web page.  Otherwise, the information on the Evaluation web page may influence your answers on the questionnaire.
  6. Why up to one week?  1) Sending your password is not an auto-reply, 2) this allows us to verify your subscription to our newsletter and/or your referred subscriber(s), which qualifies you for the Evaluation(s) of your choice, and 3) due to the volume of incoming Free Evaluations, this allows us time to assure that we are able to fulfill all requests.  Thank you for your patience. 
  7. How Do We Know Who Are Your Referred Subscribers?  On the Evaluation Request Form below, you will be asked to enter the name and email address for each of your referrals if you know who they are when you complete this request form.  If you do not know who or if you will refer anyone at this time, but later choose to do so, please ask the person you refer to put your name and email address on the Subscription Information Form, the space provided for "Who or What Referred You?" when they subscribe to our newsletter.
  8. Please be sure that you add our email address to your "accepted email" feature so that your Questionnaire and issues of your HealthQuest e-Newsletters will not go to Junk Mail. Thank you for subscribing.
  9. Should you have any questions about your Questionnaire, the Evaluation Results or any information on its Evaluation web page, please feel free to schedule an Inquiry Telephone Consultation with Dr. Smith, at no charge, by calling (940) 761-4045.
Links to information on each Free Evaluation is provided in the right column so you may read about each one to make your selection.  Thank you.

 
     
Toxicity Questionnaire
Request Form



 
EVALUATION REQUEST FORM - PLEASE CAPITALIZE ALL ANSWERS. THANK YOU. Date:
First, Middle Initial, Last Name:
Birthdate
Age
E-mail Address
Who or What Referred You to us? If internet search, please list keywords.
Cell Phone() -
Daytime Phone (Is this Home or Work#)() -
Evening Phone (Is this Home or Work#)() -
Best Days To Call (M-F)
Best Times of Day (C.S.T.)
Address Line 1
Address Line 2
City
State
Zip Code
Country
I am completing the DEO (Diet) Yes/No
Have you completed a DEO before? Yes or No
I am completing the NSQ (Nutrient Supplements - Symptoms Warrant Supplementation (Yes/No)
Have you completed a NSQ before? Yes or No
I am completing the Stress Opinionnaire (Yes/No)
Have you completed a Stress Opinionnaire before? Yes or No
I am completing the Toxicity Questionnaire (Yes/No)
Have you completed a Toxicity Questionnaire before? Yes or No
Do you want to schedule a Free Telephone Consultation with Dr. Smith to discuss the Evaluation Results? Yes, No, Maybe, Depends On The Results?
What prompted you to browse our website and what are you specifically wantinig help with or questions you want answered?
Are you interested in improving your overall health, starting with your most challenging health concerns, help with just your major health concerns, or a one-time nutritional support program to speed recovery of an acute illness or injury, or all of the above, as needed?
What is the approximate number of years you have been taking vitamins or other food supplements? Provide date or put "Never Taken."
Is there any other information Dr. Smith should know in assessing your Evaluation?
List of Names and Emails of People You Referred To Obtain Additional FREE Evaluations. Referrals are the highest compliment you can give us and we thank you, warmly.
 

Four Free Evaluations
To Choose From...


  • Dietary Evaluation Overview (DEO)
  • Nutrient Supplement Questionnaire (NSQ)
  • Stress Opinionnaire (SO)
  • Toxicity Questionnaire (TQ). 

After reading this webpage regarding the Toxicity Questionnaire/Evaluation, you may click on the above links to review information on the other 3 of the 4 FREE Evaluations to make a decision regarding which FREE Evaluation you would like to select as our "Thank You For Subscribing."  Then by referring three more friends to subscribe, you qualify for all Four Evaluations.  Complete the EVALUATION REQUEST FORM  to receive Passcodes to open web page for the Questionnaire and Evaluation you have selected.

 

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:  April 20, 2014