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Patient
Information Sheet
Doctor/Clinic___________________________________Date________________
Patient________________________________________ Age_______ Sex______
1st Analysis______ Repeat Analysis ________ Weight _________
lbs.
Height__________inches ABO Blood Type_____Rh___
1)
CHEM SCREEN PROFILE
- with
CBC and Diff_________
- with
URINE ANALYSIS_________
- with
TSH_________
- with
T4_________
- with
T3 (Total or RIA)_________
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9)
FSH_________ |
| 10)
PROLACTIN_________ |
11)
TESTOSTERONE (blood, saliva, urine)
- TOTAL_________
- FREE
_________
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2)
TRACE & TOXIC MINERALS
- WHOLE
BLOOD_________
- SERUM__________
- HAIR___________
- URINE___________
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12)
DHT_________ |
| 13)
PSA____________ |
3)
AMINO ACID PANEL
- BLOOD_________
- 24
hr. URINE_________
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14)
DHEA (blood, saliva, urine)
- TOTAL_________
- FREE_________
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| 4)
SYMPTOMATIC HISTORY_________ |
15)
CORTISOL (blood, saliva, urine)
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5)
ESTROGEN (blood, saliva, urine)
- FOLLICULAR
(Early orLate)_________
- LUTEAL_________
- MENOPAUSAL_________
- MALE_________
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16)
ALDOSTERONE_________ |
| 17)
ACTH_________ |
6)
PROGESTERONE (blood, saliva, urine)
- FOLLICULAR
(Early or Late)_________
- LUTEAL_________
- MENOPAUSAL_________
- MALE_________
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18)
GROWTH HORMONE_________ |
| 19)
FOOD ALLERGIES_________ |
| 7)
PREGNENOLONE_________ |
20)
FATTY ACIDS_________ |
| 8)
LH_________ |
21)
OTHER_________ |
Send or fax
this completed and signed form to:
Nutrabalance
c/o Total Health Enterprises
4740 Table Mesa Drive, Suite B
Boulder, CO 80305
Phone: 800-468-7903
Fax: 720-304-6527
info@nutrabalance.com
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