Functional Nutrition Evaluation

ABCD Order Form

Patient Name_______________________________________ DOB____________________ Date___________________

A NTHROPOMETRICS: Body Composition, Vital Signs, and Functional Tests Requested

Weight in lb/kg; Current______________ Gain of_______________ Loss of_______________ in past_________ months
o Body Composition Evaluation o Vital Signs o Functional Tests
(all or individually requested) (all or individually requested) (all or individually requested)
o BMI – Weight, Height, & Body Mass o Temperature o O2Sat – Oxygen Saturation
Index o Left/Right Pulse (Pulse Oximetry)
o WC – Waist Circumference o BP Left and Right Arm o PEFR – Peak Expiratory Flow
o WHtR – Waist to Height Ratio o Respiratory Rate Rate
o WHR – Waist to Hip Ratio o HRV – Heart Rate Variability
o BIA – Bioelectrical Impedance o Other
Analysis ___________________________________________________________
o BMR – Basal Metabolic Rate ___________________________________________________________
(calculated) ___________________________________________________________

B IOMARKERS: Laboratory Tests Requested

Circle appropriate tests Pyridinium Crosslinks, Vitamin K: PT, PTT n Serum Vitamin B12 (Cobalamin):
Deoxypyridinoline, …), PTH, Phylloquinone (K1), Under- Homocysteine, MCH, MCV,
Protein
Urinary Ca2+ carboxylated Osteocalcin MMA, Serum B12 n MTR SNPs,
Albumin, Globulin, Total Protein n
Copper: Ceruloplasmin, Vitamin B1 (Thiamine): MTRR SNPs
Carnitine, Plasma Amino Acids,
Serum Copper n RBC Copper Plasma Thiamine n RBC Vitamin C (Ascorbic Acid):
Prealbumin-Transthyretin n
Iodine: Spot First Morning Transketolase Index n Plasma Serum Vitamin C, WBC Vitamin C
Methylhistadine, Fibronectin,
Urine Iodine, 24 Hour Urine Iodine Isoleucine, Urine Isocaproate,
Serum Proteins Electrophoresis, Phytonutrients
Iron: CBC (Hgb, Hct, MCV, Urine Isovalerate, Urine 8-OHdG, Lipid Peroxides,
Somatomedin C, Transferrin,
MCH), Ferritin, HFE Gene Panel, Methylvalerate
Urinary Amino Acids Oxidized LDL, Total Antioxidant
Serum Iron, TIBC, Transferrin Vitamin B2 (Riboflavin): Capacity n RBC Glutathione,
Fats Magnesium: RBC Mg2+, Plasma Riboflavin n Urine Serum CoQ10
ApoA1, ApoB, ApoB/A1 Ratio n Serum Mg2+ n 24 hour Urinary Ethylmalonate, Urine
Lipid Panel and Ratios (TC, LDL, Mg,2+ Buccal Cell Mg,2+ Ionized Methylsuccinate Foundational Testing
HDL, TG), Lipid Particle Number, Mg2+ by NMR n Mg2+ Load Vitamin B3 (Niacin): CBC w/diff, CMP
Size, Subfractions, TG/HDL Ratio Phosphorus: Serum Phosphorus N-Methylnicotinamide, Urine Other Functional Testing
n Omega 3 Index, Oxidized LDL,
Selenium: Serum Selenium n Lactate, Urine Pyruvate Autoimmune Panel, Celiac
Plasma EFA panel, RBC EFA Panel RBC Selenium n Glutathione Vitamin B6 (Pyridoxine): Genetic Testing, Celiac Serology,
Carbohydrates Peroxidase Homocysteine, Plasma P5P Heavy Metal Assessment, IgE
Fasting Blood Glucose, Fasting Zinc: Plasma Zn2+ n 24 Hour nUrine Kynurenate, Urine Food/Environment, IgG/
Insulin, GGT, HgA1c, HOMA-IR Urinary Zn2+, RBC Zn2+ n Serum Xanthurenate n CBS SNPs, IgG4 Food Sensitivity, Intestinal
Score, Uric Acid n Adiponectin, Metallothionein Methionine Load Test, Tryptophan Permeability, Organic Acid
Fructosamine n ½ hr gtt for Vitamins Load Test Testing, Sex Hormone Testing,
glucose and insulin, 1 and 2 hr gtt Vitamin A: Serum Beta Vitamin B7 (Biotin): Urine Stool Testing for Infection and
for glucose and insulin Carotene, Serum Retinol n Alpha and Beta Hydroxyisovalerate Absorption, Hydrogen Breath
Minerals Retinol Binding Protein Vitamin B9 (Folate): Test, Thyroid Panel with Auto-
Vitamin D: 25 OH2 D3 n 1,25 Homocysteine, MCV, Serum antibodies, Urinary Dysbiosis
Calcium: Ionized Ca2+, Serum
OH2 D3 n Ionized Ca,2+ PTH, Folate n RBC Folate, Urine Markers
Ca2+ n 1,25 OH2 D3, 25 OH2 D3,
VDR Gene Panel (Bsm1, Fok1,Taq1) FIGLU n COMT SNPs, Other__________________
Bone Resorption Markers (24
Vitamin E: Alpha Tocopherol, MTHFR (677, 1298,…) SNPs,
Hour Urine Ca,2+ 24 Hour Urine ______________________
Gamma Tocopherol, SerumVitamin E Unmetabolized Folic Acid
Protein, N-Telopeptide, ______________________
n Designates seperation of first, second, and third tier testing.
Version 2 © 2015 The Institute for Functional Medicine
 C LINICAL INDICATORS: Nutrition-oriented Physical Exam Requested

o Nutrition-oriented o Soft/Hard Palate o Musculoskeletal: o Neuro:

Physical Exam o Tongue o Musculature o Cranial Nerves
(all or individually requested) o Coating o Skeleton/Joints o Vision/
o Head: o Taste Bud o Upper Extremity Color Vision
o Hair Distribution Distribution o Hands o Visual Contrast
o Scalp o Gums o Lower Extremity o Smell Test
o Face o Mucosa o Feet o Strength
o Eyes o Teeth o Skin: o Grip Strength
o Eyelids o Swallow o Get Up and Go
o Temperature
o Conjunctiva o Breath Odor o Reflexes
o Color
o Lens o Neck: o Hydration o Sensation
o Iris o Lymph Nodes o Lesions o Vibratory Sense
o Pupils o Thyroid o Bruising o Monofilament
o Ears o Chest: o Edema o Position Sense
o Nose o Hair Asymmetry o Hot/Cold
o Cardiopulmonary
o Sinuses o Balance
o Abdomen o Nails:
o Mouth o Gait
o TMJ o Fingernails
o Lips o Toenails
o Comments______________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

D IET, NUTRITION, AND LIFESTYLE: Requested

o o 1 o 3 o 7 day
Diet, Nutrition, Lifestyle Journal
o Sleep and Relaxation Assessment:___________________________________________________________________
o Exercise Clearance o Exercise Prescription o Other_______________________________________________
o Stress Assessment:________________________________________________________________________________
o Relationship Assessment:___________________________________________________________________________
o Other:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Insurance Relevant Information:

Working Diagnosis___________________________________________________________________________________
ICD 9/10 codes________________ _________________ _________________ ________________ ________________

Signature___________________________________________________ Date__________________________________

© 2015 The Institute for Functional Medicine