WHL Voeding van Iwaarde Request Form

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1. Patient details

Name

M/F

Date of birth

E-mail address

Telephone

Resid./Country

Address

Zipcode

City

2. Collection preference

Request type

3. Clinical notes

Medication/suppletion Stopped? When? Interpretation, clin. data

4. Marked tests

Test names and order are intentionally kept close to the WHL paper request form to avoid confusion for practitioners who have used the original form for years.

Search test

Quick selection — Voeding van Iwaarde

Hematology + diff. # (p) Basic panel # (g, R) Glucose (g) Insulin HOMA# (glucose + insulin) HbA1c (1p extra) CRP-HS Homocysteine (!) Iron Ferritin Transferrin TIBC / TYBC Fe-satur. (+ TBYC / iron) Vitamin panel 16 (2R, 1P !VitC) Vitamin D3 (25OH) (R) Vitamin B12 (R) Folic-acid (R) Elements in blood III / Elements Panel III (1R,1B,1p) Organic acids (U) Advanced Stool Analysis (GI360) 96-IgG food panel Histamin (B) GABA (B) Cortisol-curve# (S; K) TSH Free T3 Free T4 Reverse T3 Anti TPO Anti TG Apo-lipoprotein B Lipoprotein A Coenzyme Q10 Carnitine (tot.-free- acyl / tot.)

Panels#

Elements in blood I (1R,1B,1p) Elements in blood II (1R,1B,1p) Elements in blood III / Elements Panel III (1R,1B,1p) Elements in urine I (24U(preference) or U) Elements in urine II (24U(preference) or U) Elements in hair II (H) Vitamin panel 8 (2R, 1P !VitC) Vitamin panel 12 (2R,1P !VitC) Vitamin panel 16 (2R, 1P !VitC) Fat soluble vitamin panel (1R) Neurotransmitters I (1P; !) Neurotransmitters II (1B, 1P; !) Methylation panel (1R,2P; !) Methylation panel PLUS (1R,2P; !) Sulphur metabolites (U) Amino acids (U or 24U!) Toxic-panel in blood (P) or urine (U or 24U) Organic acids (U) Mycotoxins in Urine (Mold Exposure Test) Myco-Metabolic Insight Panel

Elements blood (B)

Sodium Potassium Calcium Magnesium Copper Zinc Selenium Cobalt Chromium Manganese Molybdenum Nickel Lithium (amm. hep. tube!) Aluminium Arsenic Cadmium Mercury (total) Lead

Elements serum (R)

Sodium Potassium Calcium Magnesium Copper Zinc Selenium Lithium Sulphur (SO4-tot.) Sulphur (SO4-free) Sulphite (SO3)

Intracellulair elements (R,B,p)

Sodium Potassium Calcium (i.c.1G extra) Magnesium Copper Zinc Chromium Manganese Vanadium

Elements urine (24U/U)

Sodium Potassium Calcium Magnesium Copper Zinc Selenium Iron Chromium Cadmium Lead Mercury Iodine Bromine Sulphur (SO4-tot.) (U) Sulphur (SO4-free) (U)

Vitamins#

Carotenoïden# (R) Vitamin A (R) Vitamin B1 (P) Vitamin B2 (P) Vitamin B3 (P) Vitamin B5 (P) Vitamin B6 (R) Biotin (B7) (P) Folic-acid (R) Vitamin B12 (R) Vitamin C (R; !) Vitamin D3 (25OH) (R) Vitamin D3 (1,25-OH2) (R) Vitamin E (R) Vitamin K1 (R) Folic-acid (erythrocyt) (R+ p)

Co-factors (R)

Carnitine (tot.-free- acyl / tot.) Coenzyme Q10 Lipoic acid Inositol Choline (total) Biopterin Glutathione-tot. (!) Glutathione ox./red. (!)

Neurotransmitters

Acetylcholine (P) Dopamine (P; !) Epinephrine (P; !) Metanephrine Norepinephrine (P; !) Normetanephrine Serotonin (P; !) Histamin (B) GABA (B) Tyramine Panel I # Panel II # Panel III #

Hematology (p)

Hematology + diff. # HbA1c (1p extra) ESR (!) D-dimeer (p!) Lymphocyte subsets

Clinical Chemistry (R)

Basic panel # (g, R) Glucose (g) Protein (total) Albumin Urea Uric-acid Creatinine Bilirubin (total + direct) Calcium Phosphate Chloride Alk. phosphatase (AF) Amylase γ-GT (GGT) ALAT (SGTP) ASAT (SGOT) LDH Creatine kinase (CK) Homocysteine (!) α-1 antitrypsin CRP-HS Cholesterol-tot. HDL-cholest. LDL-cholest (+ HDL / tot.) Cholest. / HDL ratio Triglyceride Oxidized LDL-antibody Lipoprotein A Apo-lipoprotein A1 Apo-lipoprotein B Iron Ferritin TYBC Transferrin Fe-satur. (+ TBYC / iron) PINI-score#

Endocrinology (R)

Growthormone Pregnenolone (sulfate) Aldosterone Cortisol _____ hour Cortisol (daycurve: 9 +16 h.) Transcortin Free Cortisol (+ cort. / transcort.) DHEA (-sulfate) Osteocalcin (!) PTH (!) Calcitonin (!) Insulin C-peptide IGF-1 IGF-BP3 T3 Free T3 T4 Free T4 TSH Reverse T3 Anti TPO Anti TG TSH receptor as (TSI) Prolactin FSH LH Progesterone 17β-Estradiol Estriol SHBG Testosterone Free testost. (+ test./ SHBG) Dihydrotestosterone Androstanediol (glucuronide)

Immunology (R)

ANF / ANA anti-DNA ENA ANCA AST (ASLO) Anti-CCP MBL HLA-B27 (P) IL-6 (!)

Allergy (2R)

IgE (total) 96-IgG / 27-IgE food panel 48-IgG food panel 96-IgG food panel 168-IgG VEGA panel

LTT-TEST (!)

Metals (basic)# Metals (extended)# Metals combi (basic + extended.) Borrelia (lyme)

Miscellaneous

Amino-acids (B; !) Ess. Fatty acids (B) SAM/SAH# (P; !) Nitrotyrosine (P; !) Nagalase (P; !) HIPP-panel# (2R)

(Load-) Tests

DMPS test-Hg (K) DMPS test-Hg+Cd+Pb(K) DMPS extended # (K) Iodine-load (K) Mercury-saliva(S; K) Cortisol-curve# (S; K) Intest. permeability (!) HOMA# (glucose + insulin)

Urine (24U/U)

Amino-acids ! Figlu (U) Caso-en Gliamorfine (U) Growth hormone Aldosterone Cortisol 17OH/keto Steroid.+ DHEA# ♀-Hormones# GABA (U) 6-sulf. Melatonin T3 / T4 + RT3 Reversed-T3 MDA D-Glucaric acid Methylmalonic acid Indican Kryptopyrrole HPL (+ kryptopyrrole)

Toxicology — additional WHL website tests

Aromatic Diamines Panel – Urine Bisphenols Profile (BPA, BPF, BPS) – Urine Glyphosate – Urine Isocyanate Screening – Urine Isopropylxanthone – Urine LTT – Metal Profile I MEAA / Cresol Metabolite – Urine Myco-Metabolic Insight Panel Mycotoxins in Urine (Mold Exposure Test) Organic Solvent Exposure Panel – Blood Organic Solvent Panel in Urine Persistent Organochlorine Panel – Blood Pesticide Exposure Panel – Basic (Urine) Pesticide Exposure Panel – Extended (Urine) PFAS in Blood Exposure Panel Phthalates (Plasticisers) – Urine Polycyclic Aromatic Hydrocarbons (PAHs) – Urine Toxic Heavy Metals in Blood Toxin and Detoxification Markers

Faeces

Culture (basic)# + parasitology + virulence factors + secretory IgA + pancreatic-elastase + calprotectin + α-1 antitrypsin + β-defensin 2 + M2PK + Helicobacter pylori DFT (Dual Faeces Test) Aromatogram Bacteria Aromtogram Mycose Advanced Stool Analysis Comprehensive Stool Analysis Comprehensive Stool Analysis + Parasitology Faeces Culture (Basic) GI Pathogens Profile – Multiplex PCR Stool Test Helicobacter Pylori Secretory IgA Stool Inflammation Test – Calprotectin Stool M2PK Stool Pancreatic Elastase Stool Parasitology Stool Virulence Factors Stool α-1 Antitrypsin Stool β-Defensin 2 TFT (Tripel Faeces Test) Zonulin – Intestinal Permeability

Serology (R)

IgG IgA IgM Borrelia IgG,M Candida IgA,G,M EBV Nucl. Ag (IgG) EBV IgG,M Herpes sim. IgG,M Toxoplasma IgG,M Gliadin IgA Gliadin IgG Hep. A IgG,M Hep. Bs-Ag / Core Hep. C antibodies Anti-transglutaminase IgA,G SARS-CoV-2 (COVID-19)

Saliva

♀-Hormones# (S; K) Pre-menopause (28 days) ♀-Hormones# (S; K) Post-menopause (1 day) ♂-Hormones# (S; K)

Additional tests / remarks I confirm that the patient agrees that WHL may contact them regarding this test order, payment and sample logistics.

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Practitioner

Monique van Iwaarde
Voeding van Iwaarde
info@voedingvaniwaarde.nl
https://www.voedingvaniwaarde.nl/nl/

Temporary workflow until the full practitioner portal is available in the new software.