Microsoft word - aanvraagformulier eln 02-2013 _engels_.doc

EUROPEAN
LABORATORY
Regulierenring 9 ▪ 3981 LA Bunnik ▪ The Netherlands ▪ web: www.europeanlaboratory.nl Tel: +31 30-2871492 ▪ fax: +31 30-2802688 ▪ e-mail: [email protected] (correspondence about the result is only possible with the treatment officer) NUTRIENTS
:____________________________________ M/F :________________________________________ Zipcode :___________ Resid./Country: ______________ DOB :___________ Tel.: ________________________ E-mail address: ______________________________________ Medication/suppletion: ______________________ Interpretation, clin. data: ______________________ Hereby I order the ELN/H.D.R.I. to perform the marked tests. Bill to : patient doctor / therapist

In case the bill goes to the patient:
Creditcard Master / Euro Card Visa American Express
Nr. __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Exp. date ___ ______ CVC (see backside card) ___ ___ ___ Name cardholder (printed letters) _____________________ Signature patiënt : _______________________________ Date : ___ ___ ______
Elements in blood I (1R,1G,1p)
Elements in hair I (H)
Methylation panel (3P; !)
Elements in blood II (1R,2G,1p)
Elements in hair II (H)
Sulphur metabolites (U)
Elements in blood III (1R,2G,1p)
Vitamin panel 8 (2R, 1P)
Neurotransmitters (U)
Elements in urine (24U(preference) or U)
Vitamin panel 12 (2R,1P)
Toxic-panel in blood (P)
Vitamin panel 16 (3R, 1P)
Toxic-panel in urine (U or 24U)
Elements in blood (G) Vitamins#
Hematology (p)
Endocrinology (R)
Immunology (R)
Carotene-tot. (R)
Hematology + diff. #
Vitamin A (R)
HbA1c (1p extra)
Vitamin B1 (P)
Vitamin B2 (p)
Vitamin B3 (P)
Clinical Chemistry (R)
Vitamin B5 (P)
Basic panel #
Vitamin B6 (R)
Free Cortisol (+ cort. / transcort.)
HLA-B27 (P)
Folic-acid (R)
Vitamin B12 (R)
3 (25OH) (R)
Allergy (2R)
Vitamin E (R)
Vitamin K1 (R)
Co-factors (R)
MELISA (!)
Amino-acids (U)
Amino-acids (24U)
Metals (basic) #
Elements in serum (R)
Organic acids (U)
Metals (extended) #
Figlu (U)
Miscellaneous
Growth hormone (24U)
Glutathione-tot. (!)
Aldosterone (24U)
Glutathione ox./red. (!)
Cortisol (24U)
Ess. Fatty acids (G)
Glutathion-S-transferase (G)
17OH/keto Steroid.+ DHEA (24U)
SAM/SAH# (P; !)
♀-Hormones# (24U)
Nitrotyrosine (P; !)
Neurotransmitters
Acetylcholine (P)
6-sulf. Melatonin (24U)
Nagalase (P; !)
Dopamine (P; !)
T3 / T4 (24U)
HIPP-panel# (2R)
Epinephrine (P; !)
Reversed-T3 (24U)
Intracellulair
Norepinephrine (P; !)
Free testost. (+ test./ SHBG )
Beta-Amyloidpeptide1-40(R)
elements (R,G,p)
Beta-Amyloidpeptide1-42(R)
Androstanediol (glucuronide)
Serotonin (P; !)
(Load-) Tests
Histamin (G)
Peptide hormones (K; !)
Calcium (i.c.1G extra)
DMPS test-Hg (K)
DMPS test-Hg+Cd+Pb(K)
Iodine-load (K)
Mercury-saliva (S; K)
Panel II #
Cortisol-curve # (S; K)
Panel III #
Intest. permeability (!) P.T.O.:
HOMA# (glucose + insulin)
more tests +
# : explanation
Tumormarkers (R)
Serology (R)
Explanation codes :

Catalase (G) α-fetoprotein
Culture (basic) #
♀-Hormones# (S; K)
G = Heparin tube, 8 ml
p = EDTA tube 4 ml
-Hormones# (S; K)
P = EDTA tube 8 ml
+ pancreatic-elastase Post-menopause (1 day) R = Cloth tube 8 ml
♂-Hormones# (S; K)
S = Saliva
Recoverin A (!)
U = Morning urine
24U = 24-hours urine
K = Testkit
! = Ask for the special
# : explanation see
below

Explanation:

Elements in Blood I: 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. Hematology.
Elements in Blood II: Panel elements in blood I + chromium, manganese, molybdenum, vanadium, nickel, cobalt and lead in whole blood. Selenium in serum.
Calcium and selenium intracellular.

Elements in Blood III: Panel elements in blood II + mercury, cadmium, arsenic and aluminium in whole blood. Lithium in serum.
Elements in Urine: Sodium, potassium, calcium, magnesium, iron, copper, zinc, selenium.
Elements in Hair I: Calcium, magnesium, copper, zinc, selenium, chromium, manganese, cadmium, lead, mercury.
Elements in Hair II: Sodium, calcium, magnesium, iron, copper, zinc, selenium, chromium, manganese, nickel, aluminium, vanadium, silver, cadmium, lead,
mercury, silicium, sulpher, phosphorus.

Vitamin panel 8:
carotene (pro-vitamin A), vitamin A (retinol), vitamin B3 (niacin, nicotinamide, nicotinic acid), vitamin B6 (pyridoxal-5-phosphate),
vitamin B11 (folic acid / vitamin B9), vitamin B12 (cobalamin), vitamin C (ascorbic acid), vitamin E (tocopherol).
Vitamin panel 12: panel 8 + vitamin B1 (thiamine-pyrophosphate), vitamin B2 (riboflavin), vitamin B5 (pantothenic acid), vitamin B7 (biotin / vitamin B8).
Vitamin panel 16: panel 12 + vitamin D3 (25-hydroxy-vitamin D3, 25-hydroxy-cholecalciferol) vitamin K1 (phylloquinone, phytonadione), CoQ10, Carnitine.

Methylation panel: glutathione (oxidized), glutathione (reduced), S-adenosyl-methionine (RBC), S-adenosylhomocysteine (RBC), tetrahydrofolate (THF), 5-
methyl-THF, 10-formyl-THF, 5-formyl-THF, folic acid, folinic acid, folic acid (RBC), adenosine
Sulphur metabolieten in Urine: Sulphur-total, sulphate-free, sulphite, thiosulphate, thiocyanate.

Toxic-panel in Blood (plasma): Pentane, hexane, perchloorethylene, isopropyl-acetone, benzene, methylbenzene (toluene), xylene, methyl-β-naftalene,
polychlorobifenyls (PCB’s), difluorbenzamide.
Toxic-panel in Urine: 2,5-Hexaandione (hexane-metabolites), muconic acid (benzene-metabolites), mercapturinic acid (benzene-metabolites), m-
methylhippuric acid (xylene-metabolites), p-glyoxilic acid (ethylbenzene-metabolites), dialkyl-phosphate (DAP, organofosfate-metabolites), arolein (plastic-
metabolites).
Neurotransmitters in blood: Panel I: Dopamine, Epinephrine, Norepinephrine, Serotonin. Panel II: panel I + histamine. Panel III: panel I + Metanephrine, Nor-metanephrine.
Hematology: erytrocytes, hemoglobin, hematocrit, leucocytes, MCV, MCH, MCHC, trombocytes. Differentiation: Neutrophils, lymfocytes, monocytes,
eosinophils, basophils.
Basicpanel (clinical chemistry): Glucose, protein (total), albumin, urea, uric acid, creatinine, bilirubin (total + direct), calcium, phosphate, alk. phosphatase
(AF), γ-GT (GGT), ALAT (SGTP), ASAT (SGOT), LDH, cholesterol-total, HDL, LDL, cholesterol / HDL ratio, triglyceride, iron, iron-bindingcapacity (TBYC), iron-
saturation.
MELISA (metals basic): Beryllium, cadmium, gold, phenyl-mercury, mercury (inorganic), lead, nickel, palladium, tin, titanium.

MELISA (metalen extended): Aluminium, chromium, cobalt, copper, indium, ethyl-mercury, methyl-mercury, molybdenum, platinum, silver.
MDA: malondialdehyde assay (TBARS; thiobarbituric acid reactive substances assay).

SAM/SAH: S-adenosylmethionine (erytrocyte), S-adenosylhomocysteine (erytrocyte).
Hipp-panel: Euglobulin curve, haptoglobin, orosomucoid, iron, copper, IgA, IgM, IgG.
Carotenoïden-panel: α-carotene, β-carotene, α-lycopene, β-lycopene, luteïn, zeaxanthin, β-cryptoxanthin.
Cortisol-curve (”stress-test”): Cortisol in saliva; 8 hour, 11 hour, 16 hour, 23 hour. Cortisol (total), DHEA (total).
HOMA: Homeostatic Model Assessment; quantification of insulin resistance (also known as HOMA-IR). Fasting plasma sample.
17OH/keto steroid. + DHEA in urine: 17-keto steroiden, 17-OH steroïden, DHEA, Pregnaandiol, Pregnaantriol.
♀-Hormonen in urine: 16-OH-Estron, 2-OH-Estron (E1), 4-OH-Estron, Estradiol (E2), Estriol (E3), 17-OH-Progesteron, Testosteron.

Faeces-culture (basic): pH, muscle fiber, starch, fatty soaps, aerobic / anaerobic flora (including E. coli, Enterobacteria, Bifidobacterium sp., Lactobacillus
sp.), mycology culture (including Candida sp. Aspergillus sp.).

♀-Hormones Pre-menopause (28 days), saliva: DHEA, free-testosteron + cyclus data of progesteron and estradiol.

♀-Hormones Pre-menopause (1 dag), saliva: DHEA, Estradiol, Estriol, Estron, Progesteron, Testosteron.
♂-Hormonen, saliva: Androstenedion, DHEA, Dihydrotestosteron, Estrone, Progesteron, Testosteron.

Source: http://www.europeanlaboratory.nl/documents/en/orderform_en.pdf