Name (First & Last)
Address (City, State, Zip)
Email Address
Phone Number
Height & Weight
symptoms of Nutritional Deficiency
If you answer "yes" to two or more of the following questions, you are a candidate for nutritional testing.
Do you experience fatigue?
Yes
No
Do you experience Anxiety?
Yes
No
Do you experience weight loss or gain?
Yes
No
Do you experience loss of appetite?
Yes
No
Do you experience tingling hands?
Yes
No
Do you experience muscle cramping?
Yes
No
Do you experience vomiting?
Yes
No
Do you experience heart flutter?
Yes
No
Do you experienced skin conditions?
Yes
No
Do you experience depression?
Yes
No
Do you experience bruising?
Yes
No
Do you experience reduced muscle mass?
Yes
No
Do you experience muscle weakness?
Yes
No
Do you experience diarrhea?
Yes
No
Do you experience hair loss?
Yes
No
Do you experience digestive problems?
Yes
No
Do you experience numbness?
Yes
No
Do you experience nausea?
Yes
No
Do you experience constipation
Yes
No
Do you experience impaired wound healing?
Yes
No
Do you have a low libido?
Yes
No
Symptoms of Cardiometabolic Risk
If you answer "yes" to two or more of the following questions, you are a candidate for Cardiometabolic testing.
Do you have elevated blood pressure?
Yes
No
Do you have elevated blood sugar?
Yes
No
Do you have elevated triglycerides?
Yes
No
Do you have low HDL (good cholesterol)?
Yes
No
Do you have abdominal obesity?
Yes
No
Do you experience or have concerns of polycystic ovary syndrome?
Yes
No
Unsure
Unsure
Unsure
Unsure
Unsure
Unsure
Do you experience insulin resistance?
Yes
No
Unsure
Do you experience glucose intolerance?
Yes
No
Unsure
Do you have a family history of cardiovascular disease?
Yes
No
Unsure
symptoms of Hormone Imbalance
If you answer "yes" to two or more of the following questions, you are a candidate for hormone testing.
Do you experience depression?
Yes
No
Do you experience increased anxiety?
Yes
No
Do you experience fatigue?
Yes
No
Do you experience low libido?
Yes
No
Do you have oily skin?
Yes
No
Do you have acne?
Yes
No
Do you have red or itchy skin?
Yes
No
Do you experience hot flashes or night sweats?
Yes
No
Do you have low muscle tone or bone density?
Yes
No
Do you experience insomnia?
Yes
No
Do you have breast swelling or tenderness?
Yes
No
Do you have impaired immune function?
Yes
No
Do you experience poor memory?
Yes
No
Do you experience heart palpitations? (rapid heartbeat)
Yes
No
Do you have cravings for sweets or salty foods?
Yes
No
Do you have inflammation?
Yes
No
Do you experience erectile dysfunction?
Yes
No
N/A
Do you experience infertility?
Yes
No
Do you experience menstrual irregularities?
Yes
No
N/A
Do you have concerns of accelerated aging?
Yes
No
Do you experience "brain fog"?
Yes
No
Do you experience increased bowel movements?
Yes
No
Do you have skin tags?
Yes
No
Do you experience weight gain around midsection?
Yes
No
Practitioner's Name
Practitioner's Practice
Practitioner's Phone Number
Are you interested in micronutrient testing?
Yes
No
Are you interested in Cardiometabolic testing?
Yes
No
Are you interested in genetic testing?
Yes
No
Interested in Spectracell Nutritional, Cardiometabolic, Hormone and/or Genetic testing?
Please fill out the following form. We will contact you with our testing recommendations.
Are you interested in hormone testing?
Yes
No
Please list all medications including supplements:
Would you like to receive emails from our pharmacy regarding upcoming promotions/events? This information is never shared.
Yes
No
who referred you: