ABCDs of Functional Nutrition Assessment-Nutrition Physical Exam & Lab Request

Patient Name______________________________________ DOB____________________ Date_____________

Referring Provider__________________________________ Signature____________________________________

ANTHROPOMETRICS

PCP-FNP Request For Nutrition Physical Exam and Labs

Complete Body Composition Evaluation BIA-Bioelectrical Impedance Analysis
BMI-Body Mass Index
WC-Waist Circumference BMR-Basal Metabolic Rate
WHR-Waist to Hip Ratio

BIOMARKERS AND FUNCTIONAL LABS (POMFAB)

PROTEIN Iodine Vitamin A serum Homocysteine
Albumin Spot urine Carotenoids serum FIGLU
Amino acid panel 24-hour urine 25 OH Vitamin D2 & D3 MTHFR SNP C677T
BUN
Iodine load 1,25 OH Vitamin D2 & D3 MTHFR SNP A1298C
Transferrin
Iron panel Vitamin E serum B12 serum
Other: _______________
Hemoglobin Vitamin K plasma Methylmalonic acid
OILS MCV Osteocalcin Thiamin serum
EFA spot/plasma/RBC Serum iron Prothrombin Riboflavin serum
Lipid panel (TC, LDL, HDL, TG) TIBC Other: _______________ Pantothenic acid serum
Particle Size Transferrin Pyridoxine serum
ANTIOXIDANTS
Apo B/A1 Ratio Iron saturation Organic acids
CoQ10 serum
Other: _______________ Ferritin Other: _______________
Lipid peroxides
HFE SNP
8-OHdG OTHER FUNCTIONAL
MINERALS Magnesium RBC
Other: _______________ ASSESSMENTS
Mineral panel Potassium RBC
Food allergies
Calcium ionized Selenium RBC/serum B VITAMINS
Glucose fasting/2hr
Calcium RBC/ 24 hr urine Zinc RBC/serum CBC
HgbA1C
Copper ceruloplasmin Other: _______________ Hgb/Hct/MCV/MCH
Insulin fasting/2hr
Copper RBC/serum Folate RBC
CMP, GGT, hsCRP
Electrolytes FAT SOLUBLE VITAMINS

PCP-FNP Request For Nutrition Physical Exam and Labs

 CLINICAL INDICATORS
Physical Exam Findings Not Done: _____ Done-Findings Below: _______ or See Attached Note: _____
Hair Mouth Lungs Skin Strength Temperature
Scalp Lips Heart Turgor Vibratory BP
Face Tongue Abdomen Fingernails Monofilament Heart rate
Eyes Gums Skeleton Toenails Hair symmetry RR
Conjunctiva Teeth Major joints Edema Peak flow Other findings
Ears Mucosa Minor joints Neuro- Smell test
Nose Neck Muscle Gait Vision
DIET AND LIFESTYLE ASSESSMENT
Exercise Assessment
Stress Assessment
Sleep History and Pattern Review
Other Lifestyle
Assessment____________________
24 Hour Diet Recall
3 Day Diet Assessment Exercise Assessment
Stress Assessment
Sleep History and Pattern Review