OTHER Glucose (82947) Client ID: Myeloperoxidase (83876) Lp-PLA, Activity (83698) High-Sensitivity CRP (hs-CRP) (86141) Microalbumin/Creatinine (82043/82570) ADMA/SDMA (82542) Oxidized LDL (83516) F,-Isoprostance/Creatinine (82542/82570) INFLAMMATION Standard Lipid Panel (Includes non-HDL cholesterol) (80061) If TGs > 400 mg/dL, reflex to a Direct DL (83721) ApoB (82172) ApoA1 (82172) sdLDL (83701) Lp(a) (83695) HDL2b (82664) NMR LipoProfile ® with Lipids (83704/80061)* ADVANCED LIPIDS Insulin (83525) Reflex to Adiponectin if indicated (83516) OGTT (82951) GLYCOMARK ® (84378) HbA1c (83036) DIABETES Galectin-3 (82777) NT-proBNP (83880)* HYPERTENSION/HEART FAILURE Reflex to GLYCOMARK ® if indicated (84378) Adiponectin (83516) Fructosamine (82985) C-Peptide (84681) Cystatin C (82610) Homocysteine (83090) Coenzyme Q10 (82542)* Vitamin D, 25 OH (82306) Vitamin D2/D3 (82306) Folate (82746) RBC Folate (82747) Vitamin B12 (82607) VITAMINS/SUPPLEMENTS Testosterone, Total (84403) Estradiol (82670) FSH (83001) Luteinizing Hormone (83002) Progesterone (84144) T4, Free (84439) TE. Total (84436) T3, Free (84481) T3, Total (84480) THRYROID FUNCTION Practice Name: Practitioner ID: Practitioner Name: NPI: Address: City: Phone: PRACTITIONER INFORMATION State: Fax: Zip: Time: Initials: Draw Date: PSA, Total (84153) Reflec to PSA, Free if indictated (84154) Reflec to PSA, Free if indictated (84154) CANCER PSA, Total (G0103; Medicare) AspirinWorks ® (84431/82570) COAGULATION/PLATELET FUNCTION Fibrinogen Mass (85385) CYP2C19 (81225) GENETICS ApoE (81401) MTHFR (81291) Factor II (81240) Factor V (81241) Ferritin (82728) ANEMIA/IRON METABOLISM Iron (83540) Serum Iron & IBC (83540/83550) TSH (84443) Reflex to T4, Free if indicated (84439) Reflex to T3, Free if indicated (84481) Basic Metabolic Panel (80048) ROUTINE PANELS Comprehensive Metabolic Panel (80053) Hepatic Function Panel (80076) Renal Function Panel (80069) Electrolyte Panel (80051) CBC/Auto Diff (85025)* STANDARD LABORATORY TESTS CBC (85027) Urinalysis (81001)* Uric Acid (84550) Creatine Kinase (82550) TB Gold-Quantiferon (86480) INFECTIOUS DISEASE __________________________ _____________ __________________________ _____________ Influenza A & B (87502) MOLECULAR TESTING Strep A/CG (87651, 87798) HSV/Vericella Zoster (suab) (87529x2, 87798) __________________________ _____________ __________________________ _____________ __________________________ _____________ __________________________ _____________ __________________________ _____________ __________________________ _____________ __________________________ _____________ * Sample must be shipped the same day collected. ** Sample must be protected from light. Date: X Practitioner’s Signature: X 16750 Red Oak Drive Houston, Texas 77090 Phone: 281-453-7855 Fax: 281-453-7636 TEST MENU (Please fill in box completely) LABORATORY REQUISITION Trichomonas (urine) (87661) PT/PTT (86510, 85730) D-Dimer (85379) SJ ASSOCIATED PATHOLOGISTS, LC PATIENT INFORMATION Address: City: Phone: Other Patient ID: Race: State: Fax: Zip: First Name: Ht: Last Name: DOB: Address: Last 4 SSN Digits: Middle Initial: BMI: Fasting Wt: American Indian/Alaskan Native White/Caucasian (Non-Hispanic) Asian Hispanic/Latino African-American Other Yes No Male Female Patient Demographics Sheet Attached PROVIDENCE PANELS Female Wellness Panel <40 Female Wellness Panel +40 Hepatitis Panel STD Panel Male Wellness Panel <50 Male Wellness Panel +50 RESP FOODS ALLERGY PANEL Thyroid Panel Antiphospholipid Panel Connective Tissue * Please see back of Requisition Form for Panel Details AUTOIMMUNE PANEL RA Panel Celiac Disease Panel Liver Disease Panel DX CODES: Z00.00 General medical exam I51.9 Cardiovascular Disease E78.9 Disorder of Metabolism E07.9 Disorder of Thyroid E34.9 Hormone/Endocrine disorder E23.0 Hypopituitarism D48.9 Immunodeficiency D50.9 Iron Deficiency Z79.891 Long term use of opioid analgesic E63.9 Nutritional deficiency E66.9 Obesity, Unspecified E23.6 Other disorders of pituitary gland R53.83 Other fatigue Z79.899 Other long-term drug therapy R53.81 Other Malaise Z12.5 Screen for prostate neoplasm E55.9 Vitamin D deficiency E56.9 Vitamin deficiency R53.1 Weakness M12.9 Arthropathy G89.4 Chronic Pain Syndrome Z13.21 Encounter for screening for nutritional disorder Z13.228 Encounter for screening for other metabolic disorder Z13.29 Encounter for screening for other endocrine disorders COMMENTS G89.28 Other Chronic postoperative pain R68.82 Decreased Libido E11.9 Diabetes II, Uncomplicated N42.9 Disorder of Prostate E03.9 Hyperthyroidism N59.9 Menopausal Disorder M19.90 Osteoarthritis M19.049 Osteoarthritis, hand M79.609 Pain in Limb M25.569 Pain, Knee G93.3 Postviral fatigue syndrome N41.9 Prostatitis R97.2 PSA, elevated M06.9 Rheumatoid arthritis M75.100 Rotator cuff shoulder syndrome M46.1 Sacroiliitis M54.30 Sciatica R06.02 SOB N92.0 Excessive/Frequent menstruation M79.7 Fibromyalgia R52 Generalized Pain R51 Headache E79.0 Hypercholesterolemia I10 Hypertension D84.9 Immune deficiency disorder R76.11 Positive PPD Z79.899 Medication Management Z77.21 Exposure to Potentially Hazardous Body Fluids Testosterone, Free (84402) HORMONES