020 7584 3881

Details of Process and Documents

URINE COLLECTION

Day 1 (day previous to the appointment I blood extraction):
DO NOT COLLECT the first morning urine (when you wake-up in the morning) => to the loo.
From the second urine, collect fill urine, each  time, the whole quantity of urine each time, all day, and night.
Day 2 (day of the appointment I blood extraction):
COLLECT the first morning urine.

24 hours urine collection stops here.

Please collect all urine into a large container (eg. empty plastic water bottle), don't stop when the bottle is full but go on with a second, third, ... bottle.
Don't change anything in your habits (drink and eat normally).
It is possible to proceed to the collection a few days in advance. Just store the urine collection into a cool place (or in the fridge).

The quality of the test results depends on the quality of the urine collection. Any missing urine or exceeding urine will disturb the test results. It is therefore absolutely compulsory to strictly follow these instructions!

12 HOUR FAST

Strictly NO FOOD, NO DRINK, NO THYROID HORMONE T3 during the last 12 hours preceding the blood extraction.

Are allowed:
water, black coffee (no milk, no sugar), plain tea (no milk, no sugar). All medication

IDENTIFICATION SHEET

SURNAME

 

Name

 

Sex

 

 

Date of Birth

 

Blood Group:

AddressPostcode / City

Country

 

 

 

Phone (private)

 

Phone (professional)

 

Mobile

 

Fax

 

Website

 

E-mail

 

Job

 

 

Date of first visit:

Referred by:

of

e-mails:gmouton@gmouton.com   acochet@cybernet.be

DIET QUESTIONNAIRE

For every food/drink, please tick the appropriate box according to how often you consume it on a scale of 0 to 4.  If you never consume it then tick the first column(0),if you consume large amounts tick the last column(4).It is essential that you consider your answer carefully and use ALL five columns to precisely reflect your intake.

FOODS

 

0

 

1

 

2

 

3

 

4

FOODS

 

0

 

1

 

2

 

3

 

4

FOODS

 

0

 

1

 

2

 

3

 

4

Milks:

Cerealcakes:

Vegetables:

Cow's milk

 

 

 

 

 

Rice cakes

 

 

 

 

 

Tomato

 

 

 

 

 

Goat's milk

 

 

 

 

 

Corn cakes

 

 

 

 

 

Aubergine

 

 

 

 

 

Sheep's milk

 

 

 

 

 

Oat cakes

 

 

 

 

 

Lentils

 

 

 

 

 

Mare's milk

 

 

 

 

 

Seeds:

Green peas

 

 

 

 

 

Soya milk

 

 

 

 

 

Sesame seeds

 

 

 

 

 

White beans

 

 

 

 

 

Rice milk

 

 

 

 

 

Linseeds

 

 

 

 

 

Red kidney beans

 

 

 

 

 

Almond milk

 

 

 

 

 

Hemp seeds

 

 

 

 

 

Speckled beans

 

 

 

 

 

Oat milk

 

 

 

 

 

Pumpkin seeds

 

 

 

 

 

French beans

 

 

 

 

 

Coconut milk

 

 

 

 

 

Sunflower seeds

 

 

 

 

 

Soya beans

 

 

 

 

 

Dairy products:

Nuts:

Chickpeas

 

 

 

 

 

Natural yogurt

 

 

 

 

 

Walnuts

 

 

 

 

 

Carrot

 

 

 

 

 

Fruit yogurt

 

 

 

 

 

Almonds

 

 

 

 

 

Pumpkin

 

 

 

 

 

Cream

 

 

 

 

 

Peanuts

 

 

 

 

 

Beetroot

 

 

 

 

 

Ice cream

 

 

 

 

 

Hazelnuts

 

 

 

 

 

Celery

 

 

 

 

 

Custard

 

 

 

 

 

Brazil nuts

 

 

 

 

 

Parsley

 

 

 

 

 

Whey protein

 

 

 

 

 

Pistachios

 

 

 

 

 

Spinach

 

 

 

 

 

Cheeses:

Cashew nuts

 

 

 

 

 

Lettuce

 

 

 

 

 

Hard cheese

 

 

 

 

 

Pecan nuts

 

 

 

 

 

Rocket

 

 

 

 

 

Cottage cheese

 

 

 

 

 

Macadamia nuts

 

 

 

 

 

Broccoli

 

 

 

 

 

Soft cheese

 

 

 

 

 

Chestnuts

 

 

 

 

 

Cauliflower

 

 

 

 

 

Goat's cheese

 

 

 

 

 

Pine nuts

 

 

 

 

 

Cabbage

 

 

 

 

 

Sheep's cheese

 

 

 

 

 

Coconut

 

 

 

 

 

Brussel sprouts

 

 

 

 

 

Ricotta (whey)

 

 

 

 

 

Fruits:

Cucumber

 

 

 

 

 

Cheese-topped dishes

 

 

 

 

 

Avocado

 

 

 

 

 

Asparagus

 

 

 

 

 

Butter

 

 

 

 

 

Banana

 

 

 

 

 

Fennel

 

 

 

 

 

Ghee

 

 

 

 

 

Mango

 

 

 

 

 

Meats:

Tofu

 

 

 

 

 

Pineapple

 

 

 

 

 

Beef

 

 

 

 

 

Breads:

Papaya

 

 

 

 

 

Veal

 

 

 

 

 

White bread

 

 

 

 

 

Passion fruit

 

 

 

 

 

Pork

 

 

 

 

 

Wholemeal bread

 

 

 

 

 

Orange

 

 

 

 

 

Lamb

 

 

 

 

 

Rye bread

 

 

 

 

 

Mandarin

 

 

 

 

 

Horse

 

 

 

 

 

Gluten-free bread

 

 

 

 

 

Grapefruit

 

 

 

 

 

Chicken

 

 

 

 

 

Cereals:

Lemon

 

 

 

 

 

Turkey

 

 

 

 

 

Muesli

 

 

 

 

 

Lime

 

 

 

 

 

Rabbit

 

 

 

 

 

Corn flakes

 

 

 

 

 

Grapes

 

 

 

 

 

Game

 

 

 

 

 

Shredded wheat

 

 

 

 

 

Kiwi

 

 

 

 

 

Cured meats

 

 

 

 

 

Rice crispies

 

 

 

 

 

Apricot

 

 

 

 

 

Black pudding

 

 

 

 

 

Porridge

 

 

 

 

 

Peach

 

 

 

 

 

Offal

 

 

 

 

 

Weetabix

 

 

 

 

 

Apple

 

 

 

 

 

Quorn

 

 

 

 

 

Starches:

Pear

 

 

 

 

 

Fishes:

Pasta

 

 

 

 

 

Plum

 

 

 

 

 

Tuna

 

 

 

 

 

Wheat

 

 

 

 

 

Cherries

 

 

 

 

 

Salmon

 

 

 

 

 

Rye

 

 

 

 

 

Strawberries

 

 

 

 

 

Mackerel

 

 

 

 

 

Barley

 

 

 

 

 

Cranberries

 

 

 

 

 

Sardine

 

 

 

 

 

Spelt

 

 

 

 

 

Blackberries

 

 

 

 

 

Trout

 

 

 

 

 

Oats

 

 

 

 

 

Blueberries

 

 

 

 

 

Herring

 

 

 

 

 

Millet

 

 

 

 

 

Raspberries

 

 

 

 

 

Anchovy

 

 

 

 

 

Rice

 

 

 

 

 

Red currants

 

 

 

 

 

Cod

 

 

 

 

 

Potatoes

 

 

 

 

 

Figs

 

 

 

 

 

Haddock

 

 

 

 

 

Sweet potatoes

 

 

 

 

 

Dates

 

 

 

 

 

Halibut

 

 

 

 

 

Corn

 

 

 

 

 

Melon

 

 

 

 

 

Plaice

 

 

 

 

 

Quinoa

 

 

 

 

 

Watermelon

 

 

 

 

 

Sole

 

 

 

 

 

Amaranth

 

 

 

 

 

Guava

 

 

 

 

 

 

 

 

 

 

 

Buckwheat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

FOODS

 

0

 

1

 

2

 

3

 

4

FOODS

 

0

 

1

 

2

 

3

 

4

FOODS

 

0

 

1

 

2

 

3

 

4

Seafood:

Oils:

Beverages:

Oyster

 

 

 

 

 

Olive oil

 

 

 

 

 

Home made fruit juices

 

 

 

 

 

Crab

 

 

 

 

 

Sunflower oil

 

 

 

 

 

Processed fruit juices

 

 

 

 

 

Prawn

 

 

 

 

 

Walnut oil

 

 

 

 

 

Squash

 

 

 

 

 

Lobster

 

 

 

 

 

Hazelnut oil

 

 

 

 

 

Coconut water

 

 

 

 

 

Crayfish

 

 

 

 

 

Coconut oil

 

 

 

 

 

Soft drinks

 

 

 

 

 

Snail

 

 

 

 

 

Palm oil

 

 

 

 

 

Sweetened drinks

 

 

 

 

 

Mussel

 

 

 

 

 

Rape seed oil

 

 

 

 

 

Cola

 

 

 

 

 

Scallop

 

 

 

 

 

Soya oil

 

 

 

 

 

Still water

 

 

 

 

 

Clam

 

 

 

 

 

Corn oil

 

 

 

 

 

Sparkling water

 

 

 

 

 

Squid

 

 

 

 

 

Linseed oil

 

 

 

 

 

Black tea

 

 

 

 

 

Spices:

Hempseed oil

 

 

 

 

 

Green tea

 

 

 

 

 

Garlic

 

 

 

 

 

Margarine

 

 

 

 

 

Herbal / fruit tea

 

 

 

 

 

Onion

 

 

 

 

 

Salt:

Coffee

 

 

 

 

 

Chillies

 

 

 

 

 

Sea salt

 

 

 

 

 

Decaf coffee

 

 

 

 

 

Black pepper

 

 

 

 

 

Table salt

 

 

 

 

 

Chocolate

 

 

 

 

 

Paprika

 

 

 

 

 

Himalayan salt

 

 

 

 

 

Alcoholic drinks / tobacco:

Mustard

 

 

 

 

 

LoSalt

 

 

 

 

 

Cider

 

 

 

 

 

Ginger

 

 

 

 

 

Sugar:

Beer

 

 

 

 

 

Curry

 

 

 

 

 

Refined sugar

 

 

 

 

 

Wine

 

 

 

 

 

Cardamom

 

 

 

 

 

Brown cane sugar

 

 

 

 

 

Spirits < 22°

 

 

 

 

 

Clove

 

 

 

 

 

Artifical sweeteners

 

 

 

 

Spirits ≥ 22°

 

 

 

 

 

Coriander

 

 

 

 

 

Xylitol

 

 

 

 

 

Tobacco

 

 

 

 

 

Yeasts:

Stevia

 

 

 

 

 

MISCELLANIOUS

Mushroom

 

 

 

 

 

Sweet foods:

Big appetite

 

 

 

 

 

Baker's yeast

 

 

 

 

 

Candies

 

 

 

 

 

Eat quickly

 

 

 

 

 

Brewer's yeast

 

 

 

 

 

Sweets

 

 

 

 

 

Need to eat often

 

 

 

 

 

Vinegar

 

 

 

 

 

Chocolate

 

 

 

 

 

Eat small amounts

 

 

 

 

 

Eggs:

Carob

 

 

 

 

 

Eat not enough

 

 

 

 

 

Chicken eggs

 

 

 

 

 

Biscuits

 

 

 

 

 

Sugar cravings

 

 

 

 

 

Duck eggs

 

 

 

 

 

Cakes

 

 

 

 

 

Evening cravings

 

 

 

 

 

Goose eggs

 

 

 

 

 

Pastries

 

 

 

 

 

Salt cravings

 

 

 

 

 

Quail eggs

 

 

 

 

 

Croissants

 

 

 

 

 

Cravings for caffeine

 

 

 

 

 

Egg white

 

 

 

 

 

Jam

 

 

 

 

 

Excessive thirst

 

 

 

 

 

Egg yolk

 

 

 

 

 

Honey

 

 

 

 

 

Low blood sugar

 

 

 

 

 

Egg protein

 

 

 

 

 

Maple syrup

 

 

 

 

 

Fried foods

 

 

 

 

 

Mayonnaise

 

 

 

 

 

Agave syrup

 

 

 

 

 

Processed foods

 

 

 

 

 

 

 

 

 

 

 

Molasses

 

 

 

 

 

Fast food