HDRI Req Form 2017

1 Requisition Form (Please fill the form completely and legibly). Patient Last Name First M/F Dr. Name Address Address City Zip State City State Zip Date of Birth Phone Dr. Signature Phone Fax Payment Required with Specimen Check (enclosed) Date Ordered Specimen Collection Date/Time Credit Card Invoice doctor E-mail Card Number Expiration Date Month Year Total Volume Urine 24 hour: ml Signature (required) Date Date sent Note for Medicare Patients ONLY: By ordering the test you agree that you have been informed that ELN / Health Diagnostics and Research Institute is not a Medicare provider and therefore services provided will not be submitted to Medicare.

2 Medication / supplements Discontinued ? If yes, when Fasting For HDRI Office use only: Bill Dr. Immediate payment from Dr. Codes: 24h = 24 hour urine, = Special tube, G = Am. Heparin 9 ml, H = Hair, K = Test kit, M = special requisition and kit required, P = EDTA tube 7ml, Ps= EDTA tube 4ml, R = Serum separator, S = Saliva, U = Morning urine B=Stool. Test panels: ADMA/SDMA/hARG/Arginine Panel (P) Enzymes Panel (1 P) Peptide Hormones Panel (8) (1P). Adrenocortex stress-test (S) Fatty Acids (P) Sulphur Panel (U). Amino Acids urine Panel (24h) Folic Acid Metabolites (5) (1P,1R) Thyroid hormones (24h).

3 Amino Acids plasma Panel (R) Hormones panel-Female (24h) Toxic Chemicals Metabolites (8) (U). Carotenoids-panel (R) Hormones panel -Male (24h) Toxic Chemicals (12) (P). Clinical Chemistry panel (1P, 1R) Metabolic Panel I (U or 24h) Vitamin (4) (1R 1P). Elements Panel (Blood only) (G) Metabolic Panel II (U or 24h) Vitamin (8) (2R, 1P). Elements Panel (Serum only) (R) Methylation Pathway (2 ) Vitamin (12) (2R, 1P). Elements I blood (1R,1Ps,2G) Methylation Pathway extended(2 ) Vitamin (16) (3R, 1P). Elements II blood (1R,1Ps,2G) Vitamin(19) (3R,1P). NADH/NADPH/ATP ( ).

4 Elements III blood (1R,1Ps,2G) Vitamin K Panel (1R). Neurotransmitters panel (3P) /(U24h). El. hair I (H) Vitamin A/D/E Panel (1R). Organic Acids urine (K). El. hair II (H) Vitamin A/D/E/K/CoQ10 Panel (1R). Elements in urine -1 (24h) Peptide Hormones Panel (4) (1P) Vitamin A/D/E/K/CoQ10/Carotenoids Panel Elements in urine -2 (24h) (1R). Single tests Elements in whole Elements urineSingle Amino Acids Others urine Hormones in urine Vitamins blood (G) Write the (24h) Write the name GABA FIGLU (U) (24h) Vitamin A (R). name of each of each requested Homocysteine Kryptopyrrole (U) Aldosterone Vitamin B1 (P).

5 Requested element element below SAM / SAH (RBC) Kryptopyrrole-24h DHEA Vitamin B2 (P). below) Cysteine HPL Cortisol Vitamin B3 (P). Methionine GABA (U) Testosterone Vitamin B5 (P). Homocysteine 6 SulfatoxyMelatonin(2 Estradiol Vitamin B6 (R). Enzymes (P) 4h) Estriol Biotin B7 (P). Other Tests Nagalase (M) Sulphite (U/24h) 17-OH Folic Acid (R). Elements serum GSH ox+red ( ) EGOT MNA/MMA (U) Progesterone Vitamin B12 (R). Single (R) Write the T3/T4/rT3 (P) ETKA Complete Urinalysis 17-Keto Steroids Methylcobalamine (R). name of each MDA (P) ESOD with Microscopy 17-OH Steroids Vitamin C (R).

6 Requested element Sulphate-free ( ) EGR Neurotransmitters in 16-OH Estrone 25-OH-Vitamin D3 (R). below) Sulphate -total ( ) EGPx Platelets/Urine (3P/U) 2-OH Estrone 1,25 di-OH (R). Sulphite (P) Catalase Dopamine TSH Vitamin E (R). Beta Amyloid MAO Epinephrine T3/T4 /rT3 Vitamin K1 (R). IgA Test (Feces) (M) Other Tests Norepinephrine T3/T4/Se Vitamin K2 (R). Transcobalamin (R) Ammonia Metanephrine Saliva (K) Choline (total/free ) (R). Tyramine (P) Nitric Oxide Nor-Metanephrine Mercury/Amalgam BH2/BH4(R). Intracellular HPA Axis (2P) Adenosine Serotonin Allergy Testing B2/FAD/FMN (R).

7 Elements(R, G) Write DMPS (K) Inosine,Uridine BioAmines (P) Stool Myo-Inositol (R). the name of each Carnitine free /total(R). DMPS+Pb Cd Hg(K). Nitrotyrosine Histamine (P) Faeces culture requested element Lipoic Acid (R). DMPS extended (K) ATP Acetylcholine (R) with parasitology below) Coenzyme Q10 (R). IgE/G4 (96) (R) NADH/NADPH Tyramine (R).. Candida Antibodies IgA (B).. (R).. e-mail: website: By sending a specimen to HDRI you accept to pay for the cost of the test in full. Specimen processed by: Version 2018-01. Explanation of Panels: ADMA/SDMA/hARG/Arginine in plasma: Assymetric dimethylarginine, Symetric dimethylarginine, Homoarginine, Arginine.

8 Adrenocortex stress profile in saliva ( stress-test ): Cortisol (Morning, Noon, Afternoon, Midnight), DHEA-S, Cortisol Burden Amino acids: Threonine, Valine, Methionine, Isoleucine, Leucine, Phenylalanine, Lysine, Histidine, Tryptophane, Aspartic acid, Serine, Asparagine, Glutamic acid, Glutamine, Proline, Glycine, Alanine, Cystine, Tyrosine, Arginine, Phosphoserine, Taurine, Phosphoethanolamine, Hydroxyproline, Sarcosine, -Aminoadipic acid, Citrulline, -Aminobutyric acid, Cystathionine, -Alanine, -Aminoisobutyric acid, Homocystine (free), Gamma-Aminobutyric acid, Ethanolamine, Hydroxylysine, Ornithine, 1-Methylhistidine, 3-Methylhistidine, Anserine, Carnosine.

9 Neurotransmitters (Catecholamines) Panel in Platelets/24h Urine.: Dopamine, Epinephrine, Norepinephrine, Serotonin, Metanephrine, Nor-metanephrine Carotenoids-panel:, lute n, zeaxanthin, -cryptoxanthin, -carotene, -carotene, -lycopene, -lycopene DMPS extended (30 elements before and after): Calcium, magnesium, copper, zinc, selenium, chromium, manganese, cadmium, lead, mercury, sodium, potassium, iron, nickel, aluminum, vanadium, silver, sulpher, phosphorus, molybdenum, cobalt, arsenic, lithium, iodine, antimony, beryllium, bismuth, bromine, platinum, tin Elements in Blood I.

10 Sodium, potassium, calcium, magnesium, copper and zinc in whole blood and serum. Selenium in whole blood. Sodium, potassium magnesium, copper and zinc intracellular. Zinc / copper ratio intracellular. Elements in Blood II: Panel elements in blood I + chromium, manganese, molybdenum, vanadium, nickel, cobalt and lead in whole blood. Selenium, chromium in serum. Chromium and selenium intracellular. Elements in Blood III: Panel elements in blood II + mercury, cadmium, arsenic and aluminium in whole blood. Cobalt, molybdenum, lead and gold in serum. Cadmium and lead intracellular.