Analytical Research Labs Order Form

INSTRUCTIONS: Complete all parts of this form.

Practitioner’s Account No: 86892
Practitioner’s Phone Number: (906) 367-3673
Practitioner’s Name: Lynda Cross
Practitioner’s Mailing Address: N7768 Ridge Road Munising, MI 49862
Practitioner’s E-mail: lynda@balancingbynutrition.com

Patient's Name

Patient's Email

Patient's Height

Patient's Weight

Patient's Age

Patient's Sex Patient's Sex M F

Patient's Occupation

Patient's Hair Color Patient's Hair Color Black Brown Blond Red Grey

Patient's Type of Specimen (do not mix) Patient's Type of Specimen (do not mix) Head Pubic Other

TISSUE MINERAL ANALYSIS ORDER TISSUE MINERAL ANALYSIS ORDER PROFILE 1 - Laboratory Mineral Test Only PROFILE 2 - Initial Lab Test and Interpretation - Entire Tissue Mineral Assay Test with charts and a thorough descriptive interpretation that lists trends, explains the results, and gives vitamin and mineral supplement recommendations PROFILE 3 - Labtest and Supplement Recommendation Only. PROFILE 4 - Progress Test and Comparision Analysis - Complete retesting of mineral levels with explanations of the results and suggested modifications to the supplement program as indicated by significant changes since previous test. PROFILE 5 - Personal Diet Plan - Addition to Profiles 2, 3, or 4

Is the Patient Pregnant? Is the Patient Pregnant? Yes No

VITAMIN AND MINERAL FOOD SUPPLEMENTS ORDER VITAMIN AND MINERAL FOOD SUPPLEMENTS ORDER DO NOT SEND SUPPLEMENTS

501 Acne 705 Addiction 502 Addiction, Alcohol 753 Addiction, Chocolate 717 Addiction, Cigarette 540 Addiction, Drug 648 Aggression 734 AIDS 502 Alcoholism 503 Allergies 504 Alopecia 616 Alopecia, Hair Loss 641 Alopecia, Poor Hair Growth 770 ALS 760 Alzheimer's Disease 506 Anemia 649 Anger 507 Angina 703 Anorexia 508 Anxiety 509 Arteriosclerosis 683 Arthritis 510 Arthritis, Ostao 687 Arthritis, Psoriatic 511 Arthritis, Rheumatoid 512 Asthma 513 Atherosclerosis 514 Autism 762 Attention Deficit Disorder

651 Back Problems 674 Bad Temper (Temper Problems) 684 Bed Wetting 515 Behavior Problems 776 Bladder Infection 755 Blood Clots 743 Blurred Vision 701 Boils 714 Breast Lump (lump in breast) 517 Breast Tumor 735 Bronchitis 634 Brown Spots on Skin 765 Bruising 518 Buerger's Disease 756 Burning Feet 519 Bursitis

Previous Lab Test #

615 Dandruff 653 Defensiveness 535 Depression 536 Dermatitis (skin problems) 537 Diabetes 538 Diarrhea 700 Difficulty Taking Supplements 617 Diminished Growth Rate 539 Diverticulosis 685 Dizziness 540 Drug Addiction 747 Dry Mouth 541 Dyslexia

704 Ear Infection 544 Eczema 545 Edema, Water Retention 654 Emotional Problems (or emotional instability or sensitivity) 546 Emphysema 711 Endometriosis 547 Epilepsy 691 Epstein-Barr Syndrome 638 Euphoric (loss of awareness) 655 Exhaustion

520 Calculus, Billary 521 Calculus, Renal 522 Cancer 652 Candida Albicans 766 Canker Sores 523 Cardiac Arrhythmia 524 Cardiovascular Disease 767 Carpal Tunnel 525 Cataracts 526 Celiac Disease 527 Cerebral Palsy 718 Chronic Fatique Syndrome 717 Cigarette Smoker 528 Cirrohosis of the Liver 529 Colitis 530 Collagen Disease 728 Compulsive Behavior 531 Constipation 532 Coronary Occlusion 618 Craving Sweets 758 Crohns' Disease 533 Cushing's Disease 534 Cystic Fibrosis

707 Gall Bladder Problems 748 Gall Stones 731 Gas (Indigestion) 656 Gastric Ulcer 550 Gastritis 551 General Good Health 552 Glaucoma 617 Growth Rate, Diminished 593 Growth Rate, Stunted 553 Gout

616 Hair Loss 641 Hair Growth, Poor 695 Headaches 572 Headaches, Migraine 754 Hearing Problems 779 Hemochromatosis 746 Hemorrhoids 724 Hemosiderosis 713 Hepatitis 733 Herpes 558 High Blood Pressure (Hypertension) 723 Hives 763 Hiatal Hernia 769 HIV Positive 554 Hodgkin's Disease 722 Hot Flashes 657 Hostility 710 Hyperactivity 555 Hypercholesterolemia (High Cholesterol) 556 Hyperkinesis 557 Hyperlipidemia 558 Hypertension (High Blood Pressure) 559 Hyperthyroidism (over active thyroid) 560 Hypoadrenocorticism 561 Hypoglycemia 561 Hypothyroidism (Under-Active Thyroid)

548 Fatigue 712 Fever 773 Fibromyalgia 549 Fractures 706 Frequent Urination 725 Fungus under Nails

759 Joint Pain

721 Keloid Scars 661 Kidney Problems 650 Kidney Stones

696 Immune Deficiency 563 Impotence (Men Only) 731 Indigestion (Bloating, Gas) 688 Infections 704 Infections, Ear 738 Infection, Respiratory 716 Infections, Yeast 658 Infertility 660 Inflammation 564 Insomnia 774 Irritable Bowel Syndrome 659 Irritability 720 Iritis

708 Memory Loss (Loss of Concentration) 568 Meniere's Syndrome 569 Menopause 729 Menstrual Problems 505 Menstrual Problems - Amenorrhea or Cessation 542 Menstrual Problems - Dysmenorrhea or Painful Periods 663 Mental Confusion 570 Mental Problems 571 Mental Retardation 750 Mind Racing 572 Migraine Headaches 692 Mononucleosis (mono) 665 Mood Swings 747 Mouth Dry 775 Multiple Chemical Sensitivity 573 Multiple Sclerosis 739 Muscles Cramps 719 Muscle Tone Poor 740 Muscle Weakness 574 Muscular Dystrophy 576 Myositis 577 Myositis Ossificans

699 Lactating Mother 565 Learning Disabilities 566 Leukemia 686 Loss of Appetite 638 Loss of Awareness (euphoric) 727 Loss of Balance 708 Loss of Concentration 662 Low Self-Esteem 714 Lump in Breast 567 Lupus Erythematosus

667 Obesity 581 Osteoporosis 694 Ovarian Pain

639 Nail Growth Poor (Poor Nail Growth) 637 Nails, Ridges on 636 Nails Soft 666 Nausea 681 Negative Feelings 726 Nervousness 578 Nervous System Dysfunction 579 Neuralgia 580 Neuritis 768 Nightmares

589 Raynaud's Disease 732 Retinitis 738 Respiratory Infection 590 Rheumatism 637 Ridges on Nails 643 Ringing in Ears

709 Pain between Shoulder Blades 751 Panic Attacks 583 Parkinson's Disease 584 Perceptual Motor Problems 585 Periodontal Disease 586 Phlebitis 752 Phobias 668 Paranoia 612 Pigmentation Problems / Skin 669 PMS 680 Poor Attitude, Outlook 745 Poor Circulation 708 Poor Concentration 731 Poor Digestion, Indigestion 640 Poor Memory 719 Poor Muscle Tone (see Muscle) 639 Poor Nail Growth 671 Pregnant 670 Protein Catabolism 669 Pre-Menstrual Tension, PMS 587 Prostate Problems 619 Psoriasis 588 Pscyological Problems

591 Schizophrenia 592 Scherodermia 715 Scoliosis 737 Sciatic Nerve Problems 757 Sexual Desire, decreased 664 Sinus Problems 749 Sinusitis 536 Skin Problems, Dermatitis 634 Skin, Brown Spots 628 Skin, Dry 744 Skin, Flaky 633 Skin, Itchy 629 Skin, Oily 741 Skin, Rash 642 Stress 771 Spider Veins 672 Stomach Problems 673 Suicidal Tendencies

594 Tachycardia 693 Taking Birth Control Pills 674 Temper Problems (Bad Temper) 772 Tendinitis 595 Thrombophlebitis 643 Tinnitus, ringing in ears 702 Tourettes Syndroms 730 Tumors 596 Tumors, Benign 597 Tumors, Fatty 598 Tumors, Fibroid (Misc.)

599 Ulcer, Skin 600 Ulcer, Gastric 601 Uremia 706 Urination Problems (Frequent Urination) 777 Urination Infection

602 Varicose Veins 675 Vegetarian 764 Vitiligo 676 Volatility

545 Water Retention (Edema) 677 Weight Gain 603 Weight Loss 678 White Spots on Nails 679 Worrying 605 Wound Healing (Poorly)

716 Yeast Infections

698 RETEST ONLY - Emotionally Stronger 697 RETEST ONLY - Feeling About The Same 689 RETEST ONLY - Feeling Better 690 RETEST ONLY - Feeling Worse

Additional Comments or Symptoms

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