ExecutiveCheckUp_Dec4_Men_EnglishVersion 2

(Sample)

Report of Comprehensive

Health Screening

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It s about time

© 2019 Novomed All Rights Reserved

Sample Report of

Novomed

Comprehensive

Health Screening

Program

Novomed Comprehensive Health Screening

Date of Examination

Name

Date of birth

Patient Number

Toll-Free: 800 6686633

Suite 30, 3004 th Floor | Marina Plaza | Dubai

Our focus on providing the most comprehensive check-up in the industry at

reasonable prices reflects our management's commitment to preventing and

reversing diseases. Interest-free and financing available

• If you have experienced any adverse reaction to contrast media or sedative medication during a

checkup at another hospital, please inform us when you make a reservation.

• Please bring any MRI, CT, labs, and checkups you have done over the last three years and a list of

your current medication.

• Please bring your ID or passport.

• Do not eat or drink anything on the day of the check up (Will serve you snacks after we draw blood)

• Bring loose clothes and wear running or tennis shoes suitable for your treadmill stress test and PFTs.

• Do not wear

or heavy make-up.

• Take your medications as prescribed by your doctor with a sip of water, except for blood thinners.

Page 5 / 5

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Fill in the questionnaire that shall be sent to your email

or smart phone ahead of booking your appointment.

The check up involves booking appointments with a

dozen doctors and professionals. A non-refundable

deposit of 1,000 AED is required.

Summary of Medical Examination

• Elevated blood glucose level, suspected to be diabetes – Consult with a specialist

•

Doctor's Name: Dr. Ghassan F. Nakad

Specialty: Interventional Cardiology Specialist

Doctor Notes:

• Overweight (pre-obesity) – Try not to gain more weight. Regular aerobic exercise and a balanced

diet are recommended.

• Abdominal obesity – it increases the risk of diabetes, hypertension, and hyperlipidemia. Manage it

through regular exercise and a healthy diet habit.

• CRP, the inflammatory indicator, is slightly elevated. It can be temporarily elevated by cold. If you

don’t have symptoms, observe for now.

• There is no hepatitis B antibody. Vaccination is recommended (0 ,1 ,6 months; 3 shots).

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Detailed Results

small variations depending on your age, current symptoms and concerns, medical history, family

Nutritional Diet

92% of food and nutrition research is conducted by institutions or doctors receiving money from the

sugar, dairy, meat, alcohol and big pharma lobbies. The research is designed to deliberately confuse

consumers with conflicting advice so that they finally give up and succumb to the thousands of ads

designed to sell their harmful food or their drugs.

Good food is the basis for good health... but do not worry about getting sick from bad food as big

pharma has a pill for every ill. And if the pill creates side effects, there is another pill to address that.

There is plenty of evidence that we should drink mostly water and avoid sugary drinks, packaged foods,

refined sugar, and substitute whenever possible, animal fat and protein with plant derived fat and

protein.

Eat in moderation even healthy food. The WHO declared that there is no such animal as “safe drinking”

as even small amounts of alcohol are cancerogenic and harm your brain. Your liver is your biggest

source of antioxidants which is what you need to clean all the poisons that we cannot escape. So do

not tax your liver with obesity, unnecessary medications or alcohol. Get enough quality sleep. After age

45, exercise is not optional. Avoid toxic relationships and keep your good friends. Never retire even if

you can afford it. Get a yearly health check-up as it is a very good investment as opposed to waiting till

it is too late.

Nutritional Diet

Nutritional Diet Report

Nutritional Diet

The obesity criteria is defined as body mass index of weight for square of height. (Low body weight , <

18.5 ~ 22.9 18.5 Standard body weight, 23 ~ 24.9 Overweight, > 25 Obesity, > 30 Morbid Overweight).

The ideal range for blood pressure is < 120/80mmHg. If the systolic is 120-139 or diastolic is

80-89mmHg, it is high of normal range (prehypertension) and if the systolic is > 140 or diastolic is >

90mmHg, it is classified as hypertension.

Body Mass Index and Blood Pressure

BMI Report

Body Mass Index and Blood Pressure

This is a test to check the number of white blood cells, red blood cells (hemoglobin), and platelets in

the blood. If you have anemia (low hemoglobin), iron-related tests (Fe, TIBC, Ferritin) may be helpful

in identifying the cause. CRP is an indicator of inflammation and infection in the body.

Reference

Results

White Blood Cells (WBC)

3

4~10 x 10 /

5.6

Red Blood Cells (RBC)

4.2~6.3 x 10^6 /

5.95

Hemoglobin

13~17 g/dL

14.8

Hematocrit

39~52 %

47.7

Mean Corpuscular Volume (MCV)

81~96 fL

80.2

Mean Corpuscular Hemoglobin (MCV)

27~33 pg

24.9

Cell Hemoglobin Concentration (MCHC)

32~36 g/dL

31.1

Red Cell Distribution Width (RDW)

11.5~14.5 %

14.3

Platelet

3

130~400 x 10 /

144

Neutrophil

50~75 %

36.6

Lymphocyte

20~44 %

49.7

Monocyte

2~9 %

9.0

Eosinophil

1~5 %

1.6

Basophil

0~2 %

0.6

C-Reactive Protein (CRP)

0~0.5 mg/dL

1.03

Basic Blood Test

Tumor marker

AFP is a tumor marker test for liver cancer, CA1-9t9 for pancreatic cancer and biliary tract cancer,

CEA for colorectal cancer, CA125 for ovarian cancer, and PSA for prostate cancer. However, tumor

markers may rise in cases other than cancer. In particular, the level of CEA may be high in smokers,

the level of CA125 may be high during menstruation, and the level of PSA may be high in benign

prostatic hyperplasia. Even if the tumor marker is normal, cancer may be present, so this test

cannot replace an examination, such as endoscopy, ultrasound, and CT.

Reference

Results

Prostatic Specific Antigen (PSA)

0~3 ng/mL 0.450

CA 19-9 (Digestive System)

0~37 U/mL

6

Alpha Fetoprotein (AFP)

0.89~8.78 ng/mL

2.14

Carcinoembryogenic Antigen (CEA)

0~5 ng/mL

1.1

Basic Blood Test

Cardiovascular Exams

Lipid blood tests are total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, Apo A, Apo B,

and etc. when LDL-cholesterol, Apo B, and triglyceride increase, the occurrence of cardiovascular

diseases is high. When HDL-cholesterol and Apo A increase, the occurrence of cardiovascular

diseases is low. LDL-cholesterol is also called as bad cholesterol and high LDL-cholesterol level

occur atherosclerosis and can lead myocardial infarction or stroke.

Reference

Results

Total cholesterol

0~240 mg/dL 169

Triglyceride 0~200 mg/dL

85

HDL-cholesterol

40~60 mg//dL

45

LDL-cholesterol

0~130 mg/dL

118

Oxidised LDL

<0.60 ug/mL

<1.0

Very Low Density Lipid (VLDL)

0~40 mg/dL

21

Inflammation Markers

Reference

Results

CRP hs

< 5.0 mg/L 1.55

Ferritin 13~50 mg/dL

31.79

Fibrinogen

200~400 mg//dL

(TG/LDL ratio)

LP(a)

< 75 nmol/I

210.30

Homocysteine

4~15 umo l/L

17.7

B12 160~800 pg/ml

241.6

Cardiovascular Exam

(

Electrocardiography

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ECG test can obtain basic information about irregular heartbeat, heart rate, and heart

Ankle Brachial Index (ABI

It is a biomarker of cardiovascular risk with both sensitivity and specificity exceeding 90%. In

addition to peripheral obstructive arterial disease about 20% of clients seen have an ABI below

0.9 carrying an increased risk of heart attack or stroke.

Stress Echocardiography

In a stress test, you walk on a treadmill that makes your heart work progressively harder. An

electrocardiogram (ECG) monitors your heart's electrical rhythms. The test sheds light on the

heart's chambers, how well the heart is pumping blood, and whether the heart has any damaged or

dead muscle.

It is useful to do for a sedentary person who suddenly wants to start exercising. Stress echo is not

100% accurate in detecting silent coronary artery disease; but helps decide what the next step

should be and is radiation free. For men with unexplained shortness of breath on exertion, or a

woman who is not sure if her pain is cardiac or anxiety related; an abnormal stress test points to a

higher risk of coronary disease. An abnormal test is more worrisome in a man or woman who also

has risk factors like a family history of heart disease, a heavy smoker, a man older than 40, a woman

older than 50, being overweight, or high small LDL cholesterol. Tests take 45 minutes.

Is a low radiation test using our new super-fast CT scan, that can be recommended by our

cardiologist or internist, as a follow up to stress echo testing; usually if you have a strong family

Cardiovascular Exam

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Electrocardiography Report

Cardiovascular Exam

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Ankle Brachial Index Report

Cardiovascular Exam

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Stress Echocardiography Report

Cardiovascular Exam

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CAC: Calcium Scoring Report

Cardiovascular Exam

Male Hormones

Testosterone

Dehydroepiandrosterone - Sulfate

Reference

Estrogen

Progesterone

0.69 30 - ~ 2.60 400 nmol/L pg/ml

Total testosterone

DHEA

65.1 - 368 ug/dl

Results

0.58

341.60

Dihydrotestosterone 0.33 - 3.01 nmol/L

1.10

Prostate ultrasound

Prostate ultrasound is an imaging examination that uses sound waves to check for any abnormalities

in the prostate. The test consists of inserting a small lubricated probe in the rectum, which creates

sound waves that bounce off the prostate and create images by using a special device. This test helps

the doctor detect the size of the prostate and diagnose any growth or problem.

Urologic Exam

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PSA

Urologic Exam

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Penile Blood Flow Report

Urologic Exam

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Prostate Ultrasound Report

Urologic Exam

s

Liver function test is essential to diagnosis of hepatitis. As the liver cells are destroyed, the serum

level of liver enzymes (ALT/GPT, AST/GOT) increases to suspect hepatitis.

Reference

Results

Total protein

6.0~8.0 g/dL

6.9

Albumin 3.3~5.2 g/dL

4.3

Total Bilirubin

0.2~1.2 mg//dL

0.7

Alkaline phosphatase

30~115 IU/L

41

AST (GOT)

64~83 g/L

73

ALT (GPT)

Amylase

28~100 U/L

67

Anti-H.pylori, Antibody, IgG

Negative IU/mL

Negative 0.621

Aspartate

Up to 35

18.3

Globulin

16-36 g/L

25

Liver fibroscan is to assess liver fibrosis as checking the liver elasticity by ultrasound. It also

analyzes quantitatively the amount of fat deposition in the liver.

Gastroenterologic Exam

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Liver Fibroscan Report

Gastroenterologic Exam

s

If HAV antibody is positive, it means you have been infected by hepatitis A or received hepatitis A

vaccination. If HAV antibody is negative, the vaccination is recommended. If HBs antigen is positive,

it means you are infected by hepatitis B. If HBs is negative and HBs antibody is positive, it means

you have received hepatitis B vaccination. If HBs is negative, hepatitis B vaccination is

recommended. If your HCV antibody test results is positive, there is a possibility of a hepatitis C

virus infection. However, it may be false and appear to be positive, even if the HCV infection has

already been cured. If your HCV antibody test result is positive, an in-depth examination is necessary.

Reference

Results

HAV antibody (IgG)

Positive

Positive

HBs antigen

Negative

Negative

Anti-HBs antibody

10 ~ mIU/mL

0.0

Anti-HCV antibody

Negative (<1.0 S/CO)

Negative

Anti-HIV antibody

Negative

Negative

Syphilis TP Ab

Nonreactive

Nonreative

Serology and Immunologic Exam

Stool Exam for parasites

An ova and parasite (O&P) exam is a microscopic evaluation of a stool sample that is used

to look for parasites that may infect the lower digestive tract, causing symptoms such as

diarrhea. The parasites and their eggs (ova) are shed from the lower digestive tract into

the stool. We only need one pea size amount of stool, the fresher the better.

H.Pylori

A positive H. pylori stool antigen that a person's gastrointestinal pain is likely caused by a

peptic ulcer due to these bacteria. A negative test result means that it is unlikely that the

individual has an H. pylori infection and their signs and symptoms may be due to another

cause.

Undigested fat

Impaired digestion or absorption can result in fatty stools. Possible causes include

salts, which reduces micelle formation, and small intestinal disease producing

malabsorption.


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Stool Exam Report


ً

Colonoscopy

Requires bowel preparation for two days prior with laxatives to empty the colon. May be

done with our CT scan also called virtual colonoscopy; more radiation but no need for

anesthesia, or with the traditional scope requiring sedation and without radiation. Must

discuss with your doctors as the test may not be necessary for your specific situation,

age and family history. Test takes 45 minutes.

Examines the esophagus, stomach and duodenum to diagnose reflux esophagitis or GERD,

esophageal cancer, gastritis, stomach ulcer, stomach cancer, and duodenal ulcer. A biopsy

can be taken when necessary for accurate diagnosis. Since it requires intravenous

sedation, it is done only if our doctors find medical reasons to subject you to it. It is done

in our Novomed Surgical Hospital in Um Suqeim (Dubai) and requires the patient to be

pre-screened by our anesthesiologist. Patients must be fasting for seven hours before

undergoing this test. Test takes 45 minutes.

٪90

المحيطية،‏ فإن حوالي ٪ 20 من العملاء الذين حققوا نسبة أقل من 0٫9 على مؤشر الضغط الكاحلي العضدي لديهم نسبة أعلى للاصابة بنوبة

قلبية أو سكتة دماغية


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Colonoscopy Report


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Esophagogastroduodenoscopy Report


Endocrinologic Exams

Blood glucose and glycated hemoglobin (HbA1c) are blood tests to diagnose diabetes mellitus.

Fasting blood sugar is a blood glucose test after 8 hours fasting. HbA1c reflects average blood

glucose level of the past 2~3 months.

Diabetes is suspected when fasting blood glucose is higher than 126mg/dL or when HbA1c is higher

than 6.5 %. In diabetic patients, blood glucose and glycated hemoglobin are also used as an index to

evaluate the blood glucose control status.

Reference

Results

Fasting Blood Sugar

~ 99 mg/dL 131

Hemoglobin A1c ~ 5.6 %

7.4

Insulin Resistance Score

less than 33

50

Thyroid function Test

TSH, T4, and T3 tests evaluate thyroid function. Hyperthyroidism or hypothyroidism can be confirmed.

Reference

Results

Thyroid Stimulating Hormone

0.35 ~ 4.94 uIU/mL 3.45

Free thyroxine ( Free T4) 0.70 ~1.48 ng/dL

0.99

Thyroid Ultrasonography

Thyroid sonography is a test to detect nodule, inflammation, and mass of thyroid gland. If thyroid

nodules with suspected thyroid cancer, it can be confirmed by thyroid biopsy (FNA).

Endocrinologic Exam

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Thyroid Ultrasonography Report

Endocrinologic Exam

Metabolic Syndrome

Metabolic syndrome is caused by abdominal obesity and insulin resistance. Insulin resistance means

that insulin action to control the blood glucose level is disturbed despite of the normal amount of

insulin, and it develops various diseases such as hypertension, dyslipidemia, diabetes mellitus,

stroke, and myocardial infarction.

When metabolic syndrome is diagnosed in comparison with having a single disease, the risk of type

2 diabetes or cardiovascular diseases such are much higher.

Metabolic syndrome is diagnosed if you

have more than 3 out of 5 risk factors

Risk Factors Diagnostic Criteria Result

Abdominal Obesity - Waist

circumference 9cm)

Triglyceride (mg/dL)

Male: >90

Female: >85

>150

98

85

HDL-Cholesterol (mg/dL) Male: < 40 / Female: < 50

45

Blood Pressure (mmHg)

> 130/85 or taking medication

120 / 85

Fasting Blood Sugar (mg/dL)

> 100 or taking medication

131

You have metabolic syndrome

Metabolic Syndrome

Vitamin D helps calcium absorption which is important for bone formation and maintenance.

Vitamin D is produced in response to sunlight hitting skin and rich in fatty fishes with blue back.

Reference

Results

25(OH) Vitamin D3 30 ~ 100 ng/mL 32.8

Is the gold standard and most accurate test to detect bone fragility and prevent osteoporosis. Bone

health is improved by quitting smoking and alcohol, weight bearing exercises, hormone rebalancing

when necessary, good nutrition and minimizing the use of medications for gastric acidity by

accurately diagnosing and fixing the underlying problem. Test takes 15 minutes.

الاستروجين

البروجستيرون

مجموع التستوستيرون

ديهيدرو إيبي أندروستيرون

Endocrinologic Exam

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DEXA Scan Report

Endocrinologic Exam

s

Microscopic urinalysis Test

Urynalysis is to see if there is blood, protein, or inflammation cell in the urine and is helpful to

diagnose kidney and urology diseases like urinary tract infection, urinary disease, or tumor.

Uric acid increases in relation with alcohol, meat consumption, and obesity and it causes gout,

kidney/urinary tract stones, and decreased kidney function.

Reference

Results

Color

(straw)

Appearance

(Clear)

pH

5.0 ~ 8.5

5.5

Specific Gravity

1.005 ~ 1.030

1.005

Nitrite

- Negative

Urobilinogen

+_

+/-

Occult blood

- Negative

Bilirubin

- Negative

Albumin

- Negative

Glucose

- Negative

Ketone

- Negative

White Blood Cells

0 ~ 4 /HPF

< 1

Red Blood Cells

0 ~ 4 /HPF

< 1

Kidney/ Urologic Exam

Kidney function is evaluated by creatinine test. The elevated creatinine level means the decline in

kidney function. If uric acid level is high, it can occurs gouts, urinary tract stone, and decreased

kidney function.

Reference

Results

Calcium

8.8 ~ 10.5 mg/dL

9.2

Phosphorus

2.5 ~ 4.5 mg/dL

3.7

Sodium (Na)

135 ~ 145 mmol/L

139

Potassium (K)

3.5 ~ 5.5 mmol/L

4.0

Chloride (CI)

98 ~ 110 mmol/L

100

Urea

10 ~ 26 mg/dL

15

Creatinine

0.70 ~ 1.40 mg/dL

0.99

Uric acid

3.0 ~ 7.0 mg/dL

7.7

Renal ultrasonography is a noninvasive study that requires no contrast and provides useful

information about the renal parenchyma. This imaging modality can be performed at the bedside in

a hemodynamically unstable patient, and it can help to detect hydronephrosis, pyonephrosis, and

perirenal abscess

Measurement of the postvoid residual by bladder scan or ultrasonography should be performed on

every patient admitted to the hospital for uraniary tract infection, irritable or nervous bladder,

prostate problems, and uraniary incontinance in women.


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Kidney Ultrasonography Report


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Bladder Ultrasonography Report


ُ

ً

s

Simple chest x-ray inspects lungs and detects lung cancer, pneumonia, and tuberculosis.

Small lung lesion cannot be detected and there is limitation to observe the lesion overlapped with

thorax structure like rib cages. Low-dose chest CT can more accurately observe lung abnormalities

than simple chest X ray and is useful for early diagnosis of various lung disease including lung

cancer.

Pulmonary function Test

What you can expect?

A spirometry test requires you to breathe into a tube attached to a machine called a spirometer.

Before you do the test, your pulmonologist will give you specific instructions. Listen carefully and

ask questions if something is not clear. Doing the test correctly is necessary for accurate and

meaningful results.The entire process usually takes less than 15 minutes.

Results:

Forced vital capacity (FVC). This is the largest amount of air that you can forcefully exhale after

breathing in as deeply as you can. A lower than normal FVC reading indicates restricted breathing.

Forced expiratory volume (FEV). This is how much air you can force from your lungs in one second.

This reading helps your doctor assess the severity of your breathing problems. Lower FEV1- readings

indicate more significant obstruction.

Should you have any problem with this screening test, we would then recommend a more

Pulmonologic Exam

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Chest X-ray Report

Pulmonologic Exam

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Pulmonary Function Test Report

Pulmonologic Exam

Skin Exams

Skin Testing

Is part of your comprehensive exam to detect suspicious skin lesions that can harbor melanomas

and an advanced infrared computerized camera to detect accelerated skin aging from smoking, sun

damage, poor nutrition, poor sleep or skin laxity from yo-yo dieting. Tests take 20 minutes.

يُستخدم الفيبروسكان لتقييم تليّف الكبد عن طريق تفحّ‏

‏ُحلّل كميّاً‏ مقدار الدهون المترسبة في الكبد

Skin Exam

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Skin Testing Report

Skin Exam

Ophthalmologic Exams

Vision and Tonometry Test

Visual acuity test is divided into the corrected vision which measures when wearing glasses or

contact lenses and the unaided vision which measures with bare eyes. The corrected vision is more

important since it measures the maximum visual acuity. Therefore, it is recommended to wear the

glasses or contact lenses that you normally wear for the visual acuity test.

Intraocular tonometry is to measure the pressure inside of eye and the compressed air is shooting

to the surface of eye using non-contact tonometer. If the pressure is high, the chance of glaucoma

occurrence is also increased. If it is severely increased, the retest can be done with contact

tonometer for more accurate measurement.

Fundus Photo

Fundus photo (retina imaging) test is a test to examine the optic disk, macula, and major retinal

vessels by photographing the center of the back of the eye. Through the examination, ophthalmic

diseases can be detected early on such as glaucoma, macular degeneration, and diabetic

retinopathy, which are major causes of vision loss, and indirectly are signs pointing to the condition

of systemic diseases, such as arteriosclerosis, can be obtained.

Ophthalmologic Exam

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Vision and Tonometry Test Report

Ophthalmologic Exam

Otorhinolaryngologic Exams

Laryngoscopy is to check the structural abnormality and tumor of larynx including the vocal

Otorhinolaryngologic Exam

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Audiometry Report


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Laryngoscopy Test Report


Dental Examination Results

Dental exam is to diagnose various oral and dental diseases through inspection and percussion by a

dentist with panoramic dental x-ray. It evaluates gum diseases, tooth decay, abrasion, damaged

fillings, broken teeth, wisdom teeth abnormality, soft tissue diseases in the oral cavity, or jaw joint

12

11

21

22

23

Oral Examination Results

14

15

16

Right | Left

24

25

26

*Prevention

-Needs proper tooth-brushin

plaque control.

17

18

Wisdom Teeth

27

28

Wisdom Teeth

-Recommends using dental floss or proxabrush (interdental brush)

for interdental cleaning.

*Periodontal Treatment

-Needs scaling. Then needs scaling annually.

48

38

47

37

46

Right | Left

36

45

35

44

34

43

42

41 31 32

33

تصوير الغدة الدرقية بالموجات فوق الصوتية هو اختبار للكشف عن العقد والالتهابات والكتل في الغدة الدرقية.‏ إذا كان هناك اشتباه بوجود سرطان الغدة


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Oral Examination Test Report


Optional Tests

Depending on your medical condition, family

history, budget, and personal preferences, you may

benefit from additional tests that are now available

at much lower prices than before thanks to the

great advances in gene identification and targeted

cell therapy.

The tests are conducted in the USA at FDA approved

laboratories at an additional cost and results take

seven to ten days.

ً ً ً

results

guidebook

a step by step guide to making the most of your results

How to understand

the results

The list of food and drink intolerances are listed in order of Reaction,

Borderline and No Reaction. Here is an explanation of what each

category means.

Reaction

Borderline

Indicates raised IgG antibody levels to these

food or drink ingredient(s) and you should try to eliminate

them completely from your diet.

Indicates a borderline reaction to these food and drink

ingredient(s) and you may benefit by limiting their

consumption.

No

Reaction

These ingredients can be eaten without restriction, unless

you already know that they cause a reaction and you have

been avoiding them, in which case you should continue to

do so.

Book the nutritional consultation

_______________________________________________________________________

To help get the most from your results and to make the changes as

easy as possible, we provide a telephone consultation with one of our

Novomed Centers registered Nutritional Therapists.

To book your appointment simply call our

Customer Care team upon receiving the

results. Once the appointment is booked, our

Nutritional Therapist will call you and your

consultation will last 30 minutes. Please come

prepared with a list of questions to ensure you

get the most out of your appointment.

N.B the advice given is

not intended to replace

any recommendations

offered by your

Doctor or Healthcare

Practitioner, as they

will have full details of

your medical history.

What to expect from your new diet

_______________________________________________________________________

You may be lucky enough to achieve good results immediately. On

average, 3 out of 4 people feel better after acting on the results of Food

Intolerance Programmes, the majority within 3 weeks.

Some people may feel worse for the first few days, this is likely to be

withdrawal symptoms – if this continues it is important to seek medical

advice. Symptoms of withdrawal can include fatigue and mood swings –

but once you have adjusted to your diet you should be back to normal.

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TOP TIPS

Always check ingredient labels – if in doubt,

don’t eat or drink it

Get as much advice as possible

Do not go without meals or fluids

Drink plenty of water

Vary your diet as much as possible

Be strict, it is the only way you know it will work

It may not be forever – many people are able to

reintroduce foods and drinks eventually

Go for basic ingredients that are not processed

or refined

Make sure you speak to one of our Nutritional

Therapists who can advise on how to keep

your elimination diet nutritious - This is

extremely important

If you have any

concerns about

any physical

changes speak

to your Doctor

or Healthcare

Practitioner.

Some of our customers find that

they notice a change in weight or

body shape; this is not a cause

for concern! You will find your

overall health improving and that

you have an increased amount of

energy.

Vitamins

&Minerals

_______________________________________________________________________

VITAMINS &

MINERALS

Vitamin A

D

E

C

B1

B2

B3

B5

B6

B12

FOLIC ACID

BIOTIN

ESSENTIAL

FATTY ACIDS

(EFA’S)

CALCIUM

MAGNESIUM

IRON

ZINC

MANGANESE

SELENIUM

CHROMIUM

FOOD TYPES

Specific nutrients can be gained from eating the following foods

red/yellow/orange fruit & vegetables, dark green leafy vegetables, dairy

products, egg yolk, cod & halibut liver oil, liver (Take care! May be high in toxins)

fortified soya milk, skin exposed to sun, dairy products, egg, fortified margarine,

herring, mackerel, salmon, oysters, cod & halibut liver oil

nuts, seeds, wholegrain cereals, vacuum packed wheatgerm, cold pressed vegetable

& nut oils, pinenuts, avocados, dairy, eggs, salmon, sardines, tuna

blackcurrants, broccoli, green peppers, strawberries, watercress, spinach, potatoes,

all fruit & vegetables

whole brown rice, potato, whole grain cereals, nuts, pulses, yeast extract, lentils,

pork, beef

lentils, green leafy vegetables, soya bean products, cereals, dairy products, eggs,

mackerel, meat

lentils, yeast extract, brewer’s yeast, nuts, pulses, dairy products, tuna, salmon,

chicken, turkey, lamb, red meats

whole grains, wheatgerm, brewer’s yeast, nuts, pulses, eggs, meat

green leafy vegetables, whole grain cereals, nuts, bananas, avocados, brewer’s yeast,

seeds, cheese, egg yolk, meat, fish, herring, oysters

fortified cereals & soya milk, fermented soya products – tempeh, miso, soya sauce,

yeast extract, barley malt syrup, edible seaweed, blackeyed beans, brewer’s yeast,

cheese, eggs, oysters, sardines, tuna, shrimp, turkey & chicken, meat, liver

green leafy vegetables, whole grain cereals, nuts, brewer’s yeast, mushroom, dates,

peanuts, root vegetables, sprouted seeds, blackeyed beans, milk, eggs, liver, kidneys

yeast, mushrooms, brown rice, nuts, brewer’s yeast, cauliflower, cabbage, watermelon, sweetcorn,

peas, tomatoes, milk, egg yolk

walnuts, seaweed, flaxseed oil, linseed, wheatgerm oil, rapeseed oil, soya beans, tofu,

hemp seeds, sunflower seed, evening primrose seed oil, nuts and seeds, oily fish

(EFA’S) EPA/DHA supplements

green leafy vegetables, broccoli, soya milk fortified with calcium, nuts, seeds – esp.

sesame/tahini, pulses, bread, fortified soya products, whole grains, dairy products esp.

low fat yoghurts, tinned fish including bones

vegetables, nuts, whole grains, green leafy vegetables, cocoa powder, wheatgerm,

brewer’s yeast, buckwheat, beans, raisins, peas, soya, crab

nuts, seeds, lentils, beans, whole grains, wheatgerm, spinach, pulses, dates, prunes,

cocoa, yoghurt, shell fish, red meat, liver, black pudding

pumpkin seeds, nuts, wholegrains, seeds, wheatgerm, pulses, some vegetables, dairy,

egg yolk, oyster, haddock, shrimp, red meats

nuts, wholegrain cereals, pulses, green leafy vegetables, tea, fruit – especially tropical

wholegrain cereals, walnuts, Brazil nuts, molasses, mushrooms, cabbage, courgettes,

cheese, eggs, cod, oysters, tuna, herring, chicken, beef, liver

molasses, rice bran, brewer’s yeast, wholegrain products, wheatgerm, green peppers,

cornmeal, apples, mushroom, asparagus, egg yolk, swiss cheese, oysters, chicken, lamb

What happens if

things go wrong?

_______________________________________________________________________

If you get a craving or have the urge to comfort eat then ask yourself why?

Is it because you are tired or fed up? If so then find an alternative. Take

a short break and a bit of fresh air for a quick fix energy boost. You don’t

need high fat or sugar food or a glass of wine to give you comfort. What

about a warming soup or mashed root vegetables or a fruit smoothie?

We often crave things that are bad for our health because they give us a

quick fix boost. This is known as masking. If you consume something your

body does not like, it triggers off a small stress response which releases

adrenaline and this gives you a short burst of energy. Unfortunately this

burst is very short lived, usually about half an hour after which time your

body feels worse than it did before because of this additional strain. Your

brain then tells you it does not like feeling this bad, it wants to experience

that boost it felt half an hour ago, so you can reach for another unhealthy

quick fix and so it goes on. Once you break this unhealthy cycle, you can

break the craving.

Even if you do give in to temptation, don’t

give up. Remind yourself how well you

have done so far and get yourself back on

track. You can learn from the experience,

think about how you can divert your

attention next time but accept the fact

that it was never going to be an easy run

from A to B. It’s not worth emotionally

beating yourself up, just move on.

You may have to go back

to square one but do not

give up –that offers no

chance of success.

It’s important not to let boredom set in, so don’t let your diet become too

samey or bland, and don’t make it dominate your life so that you stop

having a social life. If you have good friends they will understand, they

should love you for you, not your eating and drinking habits. Sadly you

may experience lack of encouragement, sarcasm or criticism from people

around you but don’t be disheartened. Try to explain the benefits you

hope to achieve or have achieved so far. Ask for their support, if it is not

forthcoming then just be

discreet with your efforts

and don’t bring it up in

conversation.

Any change brings a new

set of dilemmas but keep

reminding yourself how

you will look and feel

when improvements start

to appear and remind

yourself how far you have

managed to come.

If you don’t feel a positive change from your diet, then

review what you are doing.

| Are you being strict enough?

| Are there hidden ingredients?

| Are you being honest with yourself?

| Have you given it enough time?

| Is there some other factor in your lifestyle that is hindering your

progress?

Re-introducing

‘Reaction’ foods

_______________________________________________________________________

We recognise that many people wish to start re-introducing foods into their

diet following the exclusion processes.

This must be done with care and it is important to start slowly.

At a time convenient to your individual needs, introduce one food at a time

and leave one week between that food and the next.

If there are no symptoms after a few days then use that food on a four day

or more rotation to maintain increased tolerance.

If at any time

your symptoms

start to return or

you start to feel

ill DO NOT

continue with the

re-introduction

of that food.

Some re-introduction

suggestions

_______________________________________________________________________

Everyone is different with different ingredients to avoid, so as a general

guide the re-introduction of food and drinks may be as follows;

| If dairy has been avoided then a plain bio/live yoghurt is the best to test

first – if no reactions occur over a five-day period then try a small amount

of milk.

| If wheat has been avoided then try a wheat only product such as

Shredded Wheat. Likewise with oats, make porridge with oats and water so

it is only the oats themselves you are testing. The same is advisable with

other grains.

| Egg is best tested by trying the cooked yolk only. If there is no reaction

within five days then egg white could be tested next.

| When testing any of the foods choose a pure food to be tested so you are

positive it contains no other products.

| Always allow one week between re-introducing new ingredients. Any

reaction and symptoms need to be monitored over the testing period.

FAQs

Does cooking get rid of allergens in food?

Some people react to raw food but not cooked food. If you have a reaction

to a food on the test, you should avoid it and then test it in its different

forms individually, unless you are instructed otherwise by your Healthcare

Practitioner.

Does the programme test for reactions to other factors such

as sulphites in drinks?

Unfortunately the blood test can only test for antibody reactions to food

and drink ingredients, and sulphite reactivity cannot be tested in this way.

However, if you are reacting to sulphites in wines you may be able to

recognise a pattern in your symptoms using your Food & Drinks Diary.

Do I have to be wary of the

ingredients tested in supplements

and herbal medicines that I take?

Yes you do. The ingredients

tested are also included in many

supplements and herbal medicines

so anything you ingest needs to be

checked out to see if it is suitable.

Can I react to some parts of egg and

not to others?

Yes, we do find that some people

react to egg white and not as much to

egg yolk, or occasionally vice-versa.

Also, most but not all who react to

chicken eggs are able to tolerate duck

eggs and goose eggs without any

problem.

FAQs

Do I have to avoid alcohol all together?

With any lifestyle change it is important to review

your drinking habits, as well as other aspects of

your lifestyle. If you do react to ingredients

present in alcoholic drinks then there are usually

alternatives for you. You should discuss these when

you have your Nutritional Therapist appointment.

What milk alternatives can I use?

When people are asked to remove milk from their diet they are faced with

an array of different products that they can choose from. Supermarkets

spread their milk alternatives over

different shelves. Some can be found

next to cow’s milk in the chiller section,

some with the long-life (UHT) milks

and some in the “free-from” section.

Lactose-free milk is one of the

alternatives on offer and we often get

asked if this milk is suitable for those

needing to remove cow’s milk from

their diet. Lactose is a milk sugar, and

lactose-free milk is needed for people

that are deficient in the enzyme lactase

(they are lactase deficient and suffer

from lactose intolerance). However,

lactose-free milk is not suitable for

those reacting to dairy products as

lactose-free milk still contains the milk

proteins responsible for the intolerance

reaction. For alternatives to milk that

are suitable try soya, almond, hazelnut,

hemp, rice, oat or coconut milk

instead.

FAQs

Is there much difference between baker’s and

brewer’s yeast?

They are closely related strains of yeast and

show very little allergenic difference.

What is the importance of food families?

It has long been known that if you react to one

member of a biological family, you are more likely

to react to other members of the same family.

Is gluten free the same as wheat free?

No, a product can be wheat-free and not gluten-free and vice versa. There

are however, products which are both gluten-free and wheat-free. Read

labels carefully. Codex Alimentarius, the international standard setting

division of the World Health Organisation, divides gluten-free foods in two

groups:

1 | Consisting of, or containing ingredients such as cereals, wheat, rye

barley or oats in their constituents, which have been rendered as

‘gluten-free’

2 | In which any ingredients normally present containing ‘gluten’ have been

substituted by other ingredients not containing ‘gluten’

Gluten-free wheat starch (1) is produced by washing gluten out of wheat flour. Foods made from naturally

gluten-free ingredients (2) by their nature are free from wheat as well. If you are intolerant to wheat and

gluten, then you are advised to avoid all products containing wheat and gluten. Some people may also find it

helpful to avoid barley and rye because of the similarities of the gluten proteins found in these grains.

Your questions for your

nutritional consultation

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PHARMACOGENETIC Testing

Requisition

City State Zip

Physician

Name

Address

NPI#

City

Phone

DOB

Gender D Male

□Female

Ancestry Fax

Email

D Caucasian D Eastern European D Northern European

D Western European D Native American □ Middle Eastern

African American D Asian D Pacific Islander

Caribbean □ CentraVSouth American D Other:

□ Ashkenazi Jewish D Hispanic

----------- Specimen Type Date of

Colle tion c

1------------------------------------i D Whole Blood □ Mouthwash □ Saliva

Email

PLEASE PROVIDE LIST OF CURRENT MEDICATIONS

State

4. BILLING INFORMATION

Zip

Phone

lime of

Collection

Patient has had a blood transfusion Yes If "Yes" - Date of

□ No the last transfusion

i r:t ti ;:;!t;h;;!i had allogeneic bone marrow transplants.

□ AM

□ PM

BILL: D Insurance D HSA D Medicaid D Medicare D Se Pay D Worker's Compensation

Name of

Policyholder

DOB Medicare# Medicaid#

Relationship to Policyholder

□ Se D Spouse □ Dependant □ Other ____________________ _

Worker's

Comp.Claim#

Date of

Injury j ',

ICD-10 DIAGNOSIS CODES: _ _ _

D MEDICAL MANAGEMENT

ABCB1, APOE, COMT, CYP2C19, CYP2C9, CYP2D6, CYP1A2

CYP286, CYP3A4, CYP3A5, DRD2, Factor II, Factor V, MTHFR

OPRM1, SLCO181, VKORC1

D CARDIAC AND BLOOD CLOT

ApoE,CYP2C9,CYP2D6,CYP3A4,CYP3A5,CYP1A2,ABCB1

CYP286, CYP2C19, SLCO181, VKORC1, Factor II, Factor V, MTHFR

D PHYCHIATRY AND ADDICTION

CYP286, DRD2, CYP1A2, OPRM1, CYP2D6, CYP3A4, COMT

CYP2C19,CYP3A5,CYP2C9

D PAIN MEDICATION

CYP2C19,CYP3A4,CYP2C9,CYP1A2,CYP2D6,CYP3A5

OPRM1, COMT

D ACID REFLUX AND ANTIEMETICS

CYP3A4, CYP1A2, CYP2C19, CYP2D6, CYP2C9, ABCB1

D ANTI-SEIZURE MEDICATION

CYP3A4, CYP1A2, CYP2C19, CYP2D6, CYP2C9, ABCB1

D WARFARIN

D PLAVIX

CYP2C9 VKORC1

CYP2C19

Tests can be ordered as a panels or individually

6. PATIENT CONSENT 7. MEDICAL NECESSITY FOR TESTING

Billing ABN and Patient Plan Information: A completed Advance Beneficiary Notice (ABN) of

coverage is required for Medicare patients who do not meet medical criteria for testing. This does not

apply to specific site analyses. Insurance pre-qualification will not be performed for these tests, unless

specifically requested. All tests ordered shall be processed and billed based on payor.

Patient Acknowledgment: I am covered by insurance and authorize Novomed Specialized Clinics to

give my designated insurance plan on this form and other information provided by my health care provider

necessary for reimbursement. I authorize Novomed Specialized Clinics to inform my Plan of my test

results only test results are required for preauthorization of or payment for reflex/additional testing.

I authorize Plan benefits to be payable to Novomed Specialized Clinics. I further authorize payment of

benefits directly to the laboratory. I understand acceptance of insurance does not relieve me from any

responsibility concerning payment for laboratory services and that I am financially responsible for all charges

whether or not they are covered by my insurance. I understand that any payment I receive for services

rendered by the laboratory from my insurance provider should be forwarded immediately to the laboratory.

The data may also reveal secondary or incidental findings such as, that you may be at risk for

certain genetic diseases or you are a carrier of disease associated mutations.

Patient Consent: My signature below constitutes my acknowledgment that the benefits, risks, and

limitations of this testing have been explained to my satisfaction by a qualified health professional and

I have received a copy of the full informed consent document. I have been given the opportunity to ask

questions before I sign, and I have been told that I can ask questions at any other time. I voluntarily

agree to genetic testing.

Patient Consent for Research: □ By checking this box I DO NOT consent for the remaining part

of my sample to be used for research purposes by Novomed Specialized Clinics.

Personal information will not be shared and will be kept confidential by Novomed Specialized Clinics.

This test is medically necessary for the diagnosis or detection of a disease, illness, impairment,

syndrome or disorder, and these results will be used in the medical management and treatment for

this patient. Furthermore, additional results recipients' information is true and correct to the best of

my knowledge. The person listed as the Ordering Physician or genetic counselor is authorized by

law to order the test(s) requested herein. I confirm that I have provided pharmacogenetic testing

information to the patient and they have consented to genetic testing. Please check all that apply:

□ I confirm that the above patient's gene testing is medically necessary and the result will be

used in the medical management and dosing or consideration of medications for this

individual patient's therapy.

□ I agree to allow Novomed Specialized Clinics to transfer the information contained in this

requisition to an Letter of Medical Necessity (LMN) using the ordering physician's name as

his/her signature for insurance billing purposes.

D I have attached a LMN for insurance billing purposes.

D Patient meets clinical/genetic testing criteria for the above ordered tests.

HEALTH CARE PROVIDER'S SIGNATURE

TEST SUBMISSION CHECKLIST

If Signature is other than patient's. Printed Name ______________ _ D Copy of Patient Demographics Collected by:

□ Current Meds List

D ICD-10 Diagnosis Codes

D Patient's/Provider's Signatures

1-----------------------------------1 D Copy of Insurance Card (Front/Back)

PATIENT'S OR RESPONSIBLE PARTY'S SIGNATURE DATE □ Attach Patient's Insurance Pre-Authorization Form Signature ><

.__ ________________________________ .__ _______________________________ __,&:

Novomed Specialized Clinics • Suite 3002 - 3005 30th Floor, Marina Plaza, Dubai Marina, Dubai, UAE • Phone : 971 4 247 3100

Tests are performed in USA, results in one week.

DATE

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Letter of Medical Necessity

PHARMACOGENETIC TESTING

Date: ________ _ Patient Name: _______________________ _

DOB: _______ _ Gender: □ M □ F

Insurance Company:, _____________________ _

Subscriber Name: ______________________ _

Policy#: __________________________ _

Dear Claims Specialist:

I am writing this letter on behalf of my patient, ------------------ to request coverage for the

Pharmacogenetic testing offered through Novomed Specialized Clinics. The Pharmacogenetic testing is performed in a high

complexity CUA certified laboratory located in Frisco, Texas.

My patient has not reached their therapeutic goal on the current regimen and may be experiencing adverse drug reaction(s)

to one or more medications. I am seeking to choose safer or more efficacious dosages. I request coverage for DNA

microarray and PCR analysis of targeted genes to identify genetic variants. This knowledge will help avoid

harmful and costly adverse drug events, optimize medication dose, and increase chances of patient's treatment success.

Test Information and Impact of Results on Medical Management:

The pharmacogenetics panel offered by Novomed Specialized Clinics targets genes that when mutated are known to

impact patient's response to medication.

The result of this pharmacogenetic testing will have a direct impact on this patient's medication management.

Genetics account for much of the variability seen in our patients' responses to drug therapies and the implications of

pharmacogenetics have been well documented. Currently there are at least 230 U.S. Food and Drug Administration (FDA)

approved drugs with Pharmacogenomic information in their labeling. The labeling for some of the products includes specific

actions to be taken based on the biomarker information. In order to choose the more suitable medication and avoid potential

but serious adverse drug events, it is extremely important to perform this panel of Pharmacogenetic tests.

Patient's personal and/or family history as well as current medication regimen are suggestive of high risk for adverse drug

events based on my evaluation and review of latest available literature. In this patient's case, pharmacogenetics testing is

crucial in order to establish and confirm a genetic diagnosis, guide appropriate and immediate medical management,

predict disease prognosis, and eliminate potential adverse drug events.

Informed Consent:

The patient has provided a signed informed consent for pharmacogenetic testing, based on my discussion of the personal

and/or family history, the potential test results, and the implications for medical management. The patient is aware of the

benefits, risks, and limitations of the testing and has voluntarily agreed to the pharmacogenetic test.

Conclusion:

Knowledge of this patient's genetic information is important for me to accurately assess patient's medication regimen and

will guide my recommendations for treatment plan. I have chosen to send the patient's test to Ayass Lung Clinic, PLLC with

highly sensitive, rapid, and cost-effective pharmacogenetic which will provide helpful medical treatment planning information

for my patient.

Thank you for your review and consideration. I hope you will support this request for genetic testing coverage for my patient.

If you have questions, or if I can be of further assistance, please do not hesitate to call me at:

Sincerely,

Physician's Name: _________________________________________ _

Signature:----------------------------------------------



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Informed Consent for Genetic Testing

Genetic Testing can be complex. If warranted, obtain professional genetic counseling prior to giving consent to fully

understand what the risks and benefits are.

I request and authorize Novomed Specialized Clinics to test my (or my child's) sample for the below designated genetic

condition(s). My signature below constitutes my acknowledgment that the benefits, risks, and limitations of this testing

have been explained to my satisfaction by a qualified health professional and I have been provided a copy of the

corresponding technical bulletin describing testing for the condition(s) listed below.

DNA analysis for the condition(s):

The intended purpose is: Diagnosis / Predictive / Other:

It has been explained to me and I understand that:

• DNA test results may:

1. Diagnose whether or not I have (or my child has) this condition or am at risk for developing this condition.

2. Indicate whether or not I (or my child) am a carrier for this condition.

3. Predict another family member has, is at risk for developing, or is a carrier of this condition.

4. Be indeterminate due to technical limitations or familial genetic patterns.

5. Reveal non-paternity.

• DNA testing is specific only for the condition(s) named above and will not detect all causative mutations.

• The significance of a positive and a negative test result based on my family history has been explained.

• Although DNA testing usually yields precise information, several sources of error are possible.

These include, but are not limited to, clinical misdiagnosis of the condition, sample misidentification,

and inacurate information regarding family relationships.

• If a gene mutation is identified, insurance rates, obtaining disability or life insurance, and employability

could be affected. Federal law extends some protections regarding genetic discrimination

(http://www.genomegov/10002328). It is my responsibility to consider the possible impact of these results.

All test results are released to the ordering health care provider and those parties entitled to them by state

and local laws.

• The performance characteristics of this test were validated by Ayass Lung Clinic, PLLC. The U.S. Food and

Drug Administration (FDA) has not approved this test; however, FDA approval is currently not required for clinical

use of this test. Ayass Lung Clinic, PLLC is authorized under Clinical Laboratory Improvement Amendments

of 1988 (CLIA) and by all states to perform high-complexity testing. The results are not intended to be used

as the sole means for clinical diagnosis or patient management decisions.

• I will be responsible for payment after the genetic testing has begun, even if I decide not to receive results.

• Genetic counseling is recommended prior to, as well as following, genetic testing.

• My (or my child's) DNA sample may be stored indefinitely to be used for test validation or educational

purposes after personal identifiers are removed. No clinical tests other than the ones authorized will be

performed. I may request disposal of my blood and DNA sample following completion of the test requested

above by contacting the Ayass Lung Clinic, PLLC at 972-668-6005 or initializing in the section described below.

My signature below acknowledges my voluntary participation in the test. I understand that the genetic analysis

performed by Novomed Specialized Clinics is specific only for this disease and in no way guarantees my health,

the health of an unborn child, or the health of other family members.

Patient's Signature:

Patient's Name

OM OF

Birth Date:

Date:

I indicate my desire to opt out of participation in anonimized research studies using my DNA sample by initialing here _ __ _

Physician's or Counselor's Statement: I have explained DNA testing and its limitations to the patient

or legal guardian and answered all questions.

Physician's/Counselor's Signature:

Physician's/Counselor's Name:



Date:

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Saliva Cell Sample Collection Instruction

ORAcollect.Dx is intended for use in the

non-invasive collection of saliva samples.

Human DNA from the saliva sample is isolated,

stabilized and is suitable for use in molecular

diagnostic applications.

1. Refrain from eating, smoking, or chewing for at least 30

minutes before sample collection.

2. Donors with xerostomia (dry mouth) may not collect

adequate sample using these instructions resulting in low

yield DNA. In that case DNA extracted from whole blood is

recommended.

3. Open package from the end with the 'open here arrow'.

Saliva Cell Collection

USING ORAL SWAB ORAcollect.Dx COLLECTION KIT

4. Remove collector by its handle from the package while

ensuring that the sponge tip does not come in contact with

any surface prior to collection.

5. Place sponge as far back in the mouth as comfortable

(Figure 2).

3

®

6. Gently rub along lower gum in a back and forth motion 10

times. Avoid rubbing the teeth.

7. Choking Hazard: Caution must be taken when inserting the

sponge into the donor's mouth.

8. Repeat rubbing motion on opposite side along the lower

gum for another 10 times.

9. Hold the tube with the blue liquid upright to prevent it from

spilling.

10. Unscrew the blue cap from the tube without touching the

sponge (Fugure 3).

11. Turn the cap upside down and insert the sponge into

the tube and close the cap tightly (Figure 4).

12. Invert capped tube and shake vigorously 10 times (Figure 5).



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CARDIAC Conditions

Hereditary Assessment

Requisition

City State Zip

Physician

Name

Address

Phone DOB Gender City State

D Male D Female

Ancestry

Email

D Caucasian

D Western European

D African American

D Caribbean

D Ashkenazi Jewish

D Eastern European

D Native American

D Asian

D Central/South American

D Hispanic

D Northern European

0 Middle Eastern

D Pacific Islander

D Other:

Fax

Paben! has had a blood transfusion B s

1- ------------------------------------1 2-4 weeks of wan time is required for some testing.


Name of

Policyholder

Relabonship to Policyholder


Zip

Email

Phone

If "Yes" - Date of the last transfusion:

Specimens are not accepted for patients who have had allogeneic bone marrow transplants.

BILL: D Insurance D HSA D Medicaid D Medicare D Se Pay D Worl<er's Compensation

□ Se □ Spouse □ Dependant □ Other _____________________ _

DOB:

Medicare#

Worker's Comp

Claim#

Medicaid#

Date

of Injury


□ CARDIAC PANEL - 174 GENES

ABCC9, ABCG5, ABCG8, ACTA1, ACTA2, ACTC1, ACTN2, AKAP9, ALMS1, ANK2

ANKRD1, APOA4, APOA5, APOB, APOC2, APOE, BAG3, BRAF, CACNA1C, CACNA2D1

CACNB2, CALM1, CALR3, CASQ2, CAV3, CBL, CBS, CETP, COL3A1, COL5A1, COL5A2

COX15, CREB3L3, CRELD1, CRYAB, CSRP3, CTF1, DES, DMD, DNAJC19, DOLK, DPP6

DSC2, DSG2, DSP, DTNA, EFEMP2, ELN, EMO, EYA4, FBN1, FBN2, FHL1, FHL2, FKRP

FKTN, FXN, GAA, GATAD1, GCKR, GJA5, GLA, GPD1L, GPIHBP1, HADHA, HCN4

HFE, HRAS, HSPB8, ILK, JAG1, JPH2, JUP, KCNA5, KCND3, KCNE1, KCNE2, KCNE3

KCNH2, KCNJ2, KCNJ5, KCNJ8, KCNQ1, KLF10, KRAS, LAMA2, LAMA4, LAMP2, LDB3,

LDLR, LDLRAP1, LMF1, LMNA, LPL, LTBP2, MAP2K1, MAP2K2, MIB1, MURC (CAVIN4)

MYBPC3, MYH11, MYH6, MYH7, MYL2, MYL3, MYLK, MYLK2, MYO6, MYOZ2m MYPN

NEXN, NKX2-5, NODAL, NOTCH1, NPPA, NRAS, PCSK9, PDLIM3, PKP2, PLN, PRDM16

PRKAG2, PRKAR1A, PTPN11, RAF1, RANGRF, RBM20, RYR1, RYR2, SALL4, SCN1B

SCN2B, SCN3B, SCN4B, SCN5A, SCO2, SDHA, SEPN1, SGCB, SGCD, SGCG, SHOC2

SLC25A4, SLC2A10, SMAD3, SMAD4, SNTA1, SOS1, SREBF2, TAZ, TBX20, TBX3, TBX5

TCAP, TGFB2, TGFB3, TGFBR1, TGFBR2, TMEM43, TMPO, TNNC1, TNNI3, TNNT2

TPM1, TRON, TRIM63, TRPM4, TTN, TTR, TXNRD2, VCL, ZBTB17, ZHX3, ZIC3


Billing ABN and Patient Plan Information: A completed Advance Beneficiary Notice (ABN) of coverage

is required for Medicare patients who do not meet medical criteria for testing. This does not apply to specific

site analyses. Insurance pre-qualification will not be performed for these tests, unless specifically requested.

All tests ordered shall be processed and billed based on payor.


give my designated insurance carrier(s) plan on this form and other informabon provided by my health care

provider necessary for reimbursement. I authorize Novomed Specialized Clinics to inform my Plan of my

test results only if test results are required for preauthorizabon of or payment for reflex/additional testing.



responsibility concerning payment for laboratory services and that I am financially responsible for all charges

whether or not they are covered by my insurance. I understand that any payment I receive for services

rendered by the laboratory from my insurance provider should be forwarded immediately to the laboratory.

The data may also reveal secondary or incidental findings, such as that you may be at risk for certain

genebc diseases or that you are a carrier of disease associated mutations.

Patient Consent: My signature below consrnutes my acknowledgment that the benefits, risks, and

limnations of this testing have been explained to my satisfaction by a qualified health professional and






Personal information will not be shared and will be kept confidenbal by Novomed Specialized Clinics.

If Signature is other than patent's. Printed Name ________________ __,

This test is medically necessary for the diagnosis or detection of a disease, illness, impairment, syndrome

or disorder, and these results will be used in the medical management and treatment for this patient.

Furthermore, recipients' information is true and correct to the best of my knowledge.

The person listed as the Ordering Physician or genebc counselor is authorized by law to order the test(s)

requested herein. I confirm that I have provided genetic tesbng informabon to the patient and they have

consented to genetic testing.

Please check all that apply:

□ I confirm that the above patient's gene testing is medically necessary and the result will be used

to assess pabent for Mure cardiac conditions risk.

□ I agree to allow Novomed Specialized Clinics to transfer the information contained in this

requisibon to an LMN (Letter of Medical Necessity) using the ordering physician's name as his/her

signature for insurance billing purposes.


D Patient meets clinical/genetic tesbng criteria for the above ordered tests.

0----------------------------------t"lil



D Copy of Patient Demographics

Collected by:

D Current Meds List

lO

D ICD-10 Diagnosis Codes Print Name D Patient's/Provider's Signatures

D Copy of Insurance Card (Front/Back)

i

.Ill

PATIENT'S OR RESPONSIBLE PARTY'S SIGNATURE DATE

□ Attach Patient's Insurance Pre-Authorizaton Form Sgnature 1l

,_ _________________________________ ___. __________________________________ _,o



DATE

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Cardiovascular Genetics ICD-10 Code Reference Sheet

CODE

142.0

142.2

142.8

143

142.8

145.81

146.2

148.0

148.91

149.1

149.5

023.8

R00.2

H27.10

H52.12

134.1

171.01

171.1

171.9

177.810

J93.11

J93.81

L90.6

M35.7

O66.0

067.6

068.1

087.410

087.42

R23.3

E75.5

E78.01

E78.2

E78.4

H18.411

H18.413

125.10

125.700

125.720

125.750

125.790

G71.0

134.0

O23.0

087.89

R06.02

Z13.6

Z86.74

Z95.2

Z14.8

Z82.41

Z82.69

Z83.42

Z84.89

DESCRIPTION CODE DESCRIPTION

CARDIOMYOPATHY

Dilated cardiomyopathy 142.1 Hypertrophic obstructive cardiomyopathy

Hypertrophic non-obstructive cardiomyopathy 142.5 Cardiomyopathy, other restrictive

Other cardiomyopathies 142.9 Cardiomyopathy, unspecified

Syndromic cardiomyopathy 151.7 Ventricular hypertrophy

ARRHYTHMIA

Arrhythmogenic right ventricular dysplasia (ARVD) 144.2 Atrioventricular block, complete

Long QT syndrome 145.89 Other specified conduction disorders

Cardiac arrest due to underlying cardiac condition 147.2 Ventricular tachycardia

Paroxysmal atrial fibrillation 148.2 Chronic atrial fibrillation

Unspecified atrial fibrillation 149.01 Ventricular fibrillation

Atrial premature depolarization (PACs) 149.3 Ventricular premature depolarization (PVCs)

Sick sinus syndrome 149.8 Other specified cardiac arrhythmias

Brugada syndrome R00.1 Bradycardia, unspecified

Palpitations R94.31 Abnormal electrocardiogram (ECG)(EKG)

AORTIC ANEURYSMS/MARFAN SYNDROME

Unspecified dislocation of the lens H52.11 Myopia, right eye

Myopia, left eye H52.13 Myopia, bilateral eyes

Mitral valve prolapse 171.00 Dissection of unspecified site of aorta

Dissection of thoracic aorta 171.01 Dissection of abdominal aorta

Thoracic aortic aneurysm, ruptured 171.2 Thoracic aortic aneurysm, without rupture

Aortic aneurysm of unspecified site, ruptured 171.9 Aortic aneurysm of unspecified site, without rupture

Thoracic aortic ectasia J93.0 Spontaneous tension pneumothorax

Primary spontaneous pneumothorax J93.12 Secondary spontaneous pneumothorax

Chronic pneumothorax J93.83 Other pneumothorax

Stria Atrophicae (stretch marks) L98.8 Other specified disorders of skin and subcutaneous tissue

Hypermobility Syndrome 012.1 Congenital displaced lens

Congenital Talipes Equinovarus ("club foot") 067.5 Congenital deformity of the spine (scoliosis)

Pectus excavatum 067.7 Pectus Carinatum

Arachnodactvlv ("Conaenital deformitv of finaer(s) and hand") 087.40 Marfan svndrome

Marfan syndrome with aortic dilation 087.418 Marfan syndrome with other cardiovascular manifestations

Marfan syndrome with ocular manifestations

087.43 Marfan syndrome with skeletal manifestations

Spontaneous Ecchymoses (easy bruising)

CHOLESTEROL/CORONARY ARTERY DISEASE

Other lipid storaae disorders E78.0 Pure h'{Percholesterolemia

Familial hypercholesterolemia E78.1 Pure hyperglyceridemia

Mixed hyperlipidemia E78.3 Hyperchylomicronemia

Other hyperlipidemia E78.5 Hyperlipidemia, unspecified

Arcus senilis, right eve H18.412 Arcus senilis, left eve

Arcus senilis, bilateral eves 120.0 Unstable angina

Atherosclerotic heart disease of native 125.110 Atherosclerotic heart disease of native coronary

coronarv artery without anaina oectoris

artery with unstable anaina oectoris

Atherosclerosis of coronary artery bypass graft(s), 125.710 Atherosclerosis of autologous vein coronary

unsoecified with unstable anaina oectoris

arterv bvoass araft/s) with unstable anaina oectoris

Atherosclerosis of autologous artery coronary artery 125.730 Atherosclerosis of nonautogous biological coronary

bvoass graft(s) with unstable angina oectoris

arterv bvoass graft(s) with unstable anaina oectoris

Atherosclerosis of native coronary artery of transplanted 125.760 Atherosclerosis of bypass graft of coronary artery

heart with unstable angina pectoris

of transplanted heart with unstable angina pectoris

Atherosclerosis of other coronary artery bypass T46.6X5A Adverse effect of antihyperlipidemic and

graft(s) with unstable angina pectoris

antiarteriosclerotic drugs (statin intolerance)

OTHER

Hereditary progressive muscular dystrophy 110 Essential (primary) hypertension

Mitral valve prolapse 146.9 Cardiac arrest, cause unspecified

Aortic stenosis, congenital 020.9 Congenital heart disease (NOS)

Noonan svndrome R55 Svncooe and collapse

Shortness of breath Z01.810 Encounter for oreorocedural cardiovascular examination

Encounter for screening for cardiovascular conditions Z79.01 Long term (current) use of anticoagulants

Personal history of sudden cardiac arrest

Presence of prosthetic heart valve

Z95.0 Presence of cardiac pacemaker

FAMILY HISTORY

Genetic carrier of other disease Z15.89 Genetic susceptibility to other disease

Family history of sudden cardiac death Z82.49 Family history of ischemic heart disease and

other diseases of the circulatorv svstem

Family history of other diseases of the Z82.69 Family history of other congenital malformations,

musculoskeletal system and connective tissue

deformations and chromosomal abnormalities

Family history of familial hypercholesterolemia

Family history of other specified conditions

Z84.81 Family history of carrier of genetic disease



noven,ed

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CARDIAC CONDITIONS HEREDITARY ASSESSMENT

Date: ______________ _

Patient Name: ________________________

DOB: ______________ Gender: □ M □ F

Insurance Company: ______________________

Subscriber Name: _______________________

Policy#: ___________________________


I am writing this letter on behalf of my patient:, ______________________

to request coverage for the Hereditary Assessment for Cardiac Conditions, a genetic test offered through

Novomed Specialized Clinics. This genetic testing is performed in a CUA certified laboratory located in Frisco, Texas.

The patient is suspected to have genetic predisposition to cardiac problems.

Patient has a family history for _______________________ _

Personal and/or family history is suggestive of a higher risk for cardiac disease. I would like to assess this patient's future

Cardiac risk by performing genetic testing for Hereditary Assessment for Cardiac Conditions. The results of this genetic

test will have a direct impact on this patient's treatment and management.


Cardiac Arrest, not to be confused with a heart attack, occurs when the heart stops beating as a whole. It is the leading

cause of nontraumatic death in the United States with genetic factors constituting 25% of cardiac arrest cases. Mutations

in genes can affect the way the heart cells communicate, the strength of the heart muscle, and rhythm of the heart,

resulting in fast, chaotic heartbeats. Identifying these genetic factors plays an important role in the prognosis, of the

disease, therapy, and therefore outcome.

Informed Consent: This Hereditary Assessment for Cardiac Conditions offered by Novomed Specialized Clinics focuses

on identifying inherited cardiac conditions. It targets 174 genes with known associations to 17 inherited cardiac conditions

including cardiomyopathy, arrhythmia, hypercholesterolemia, hypertriglyceridemia, aortopathy and more. This assay is

performed using genomic DNA isolated from blood collected via capillary puncture or a swab. The test is intended for

predictive genetic testing to determine the chances that a healthy individual with or without a family history of a cardiac

condition might develop that disease. It is also performed as a pre-symptomatic genetic testing in order to

determine whether an individual with a family history of a cardiac disease, but no current symptoms, has the gene

alterations associated with the disease. Additional, it is !intended for post-symptomatic genetic testing to identify the

potential underlying cause of an existing cardiac disease. This test is a next-generation sequencing (NGS) to provide

comprehensive coverage of the genes associated with hereditary heart disease.

The patient has provided a signed informed consent for genetic testing, based on my discussion of the personal and/or

family history, the potential test results, and the implications for medical management. The patient is aware of the benefits,

risks and limitations of the testing and has voluntarily agreed to the genetic test.

Conclusion:

Knowledge of this patient's cardiac genetic information is important for me to accurately assess the patient's cardiac risks

and will guide my recommendations for the care. The value of genetic testing for these syndromes has been extensively

documented in the medical literature. In 2006, the American Heart Association, the American College of Cardiology, and

the European Cardiac Society issued joint Medical/Scientific Guidelines on the management of patients with ventricular

arrhythmias and prevention of sudden cardiac death.

Thank you for your review and consideration. I hope you will support this request for genetic testing coverage for my

patient.

If you have questions, or if I can be of further assistance, please do not hesitate to call me at: ___________ _

Sincerely,

al

E

Physician's Name: _________________________________________ _



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Patient's Name

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Date:








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HEREDITARY CANCER Testing

Requisition

City State Zip

Physician

Name

Address

Phone DOB Gender City State Zip Phone

Ancestry

Email

D Caucasian

D Western European

D African American

D Caribbean

D Ashkenazi Jewish

D Eastern European

D Native American

D Asian

D Central/South American

D Hispanic

D Northern European

0 Middle Eastern

D Pacific Islander

D Other:

D Male D Female

Fax

Paben! has had a blood transfusion B s

1- ------------------------------------1 2-4 weeks of wan bme is required for some testing.


Name of

Policyholder


Email

If "Yes" - Date of the last transfusion:

Specimens are not accepted for patients who have had allogeneic bone marrow transplants.

BILL: D Insurance D HSA D Medicaid D Medicare D Se Pay D Worl<er's Compensation

DOB: Medicare# Medicaid#

Relabonship to Policyholder

□ Se □ Spouse □ Dependant □ Other _____________________ _

Insurance

Company

Worker's Comp

Date

Claim# of Injury j'

Policy #

Group#

0 NO PERSONAL HISTORY O Ovarian Cancer, Age at Ox _ _ _

0 NO KNOWN CANCER AT THE PRESENT TIME O I AM CURRENTLY DIAGNOSED WITH CANCER

D Bladder, Age at Ox

D Melanoma, Age at Ox ___ _

□ Breast Cancer, Age at Ox

D Pancreabc Cancer, Age at Ox _ _ _

Please describe what type(s) of cancer

Date of Ox

□ Bilateral D Premenopausal □ Prostate Cancer, Age at Ox _ _ _

D Triple Negative (ER-, PR-, HER2-)

Gleason Score ___ _

□ Colorectal cancer, Age at ox

Testicular Cancer, Age at Ox _ _ _

D Gastric Cancer, Age at Ox □ Uterine/Endometrial Cancer, Age at Ox _ _

□ Kidney (Renal), Age at Ox D Colon Polyps (How Many_), Age at Ox _ _

D Other Cancer Type(s) ________________ Age at Ox. ___ _

6. FAMILY HISTORY OF CANCER 8. HEREDITARY CANCER TEST SELECTION

0 NO KNOWN FAMILY HISTORY OF CANCER

D Known familial mutation: Gene

Relationship

Gene

D Adopted (history unknown)

Mutation

Mutation

Maternal Paternal Cancer Site Age at Ox


□ HEREDITARY CANCER COMPREHENSIVE PANEL - 108 GENES

ABCB1 ;ACTRT3;AIMP2;AKT1 ;ALK;APC;AR;ARHGAP44;ATF1 ;ATM;AXIN2;BAG6;BMPR1A;

BRAF;BRCA1;BRCA2,BRIP1;BUB1B;CASC17;CASC8;CCHCR1;CDH1;CDK10;CDKN1A;

CDKN2A;CHEK2;CHRNA3;CLPTM1L;COLCA1;CTD-2194D22.4;DBNDD1;DICER1;EGFR;

EHBP1;ELAC2;EPCAM;ETS2;FGF10;FGFR4;FH;FLACC1;FLCN;HNF1B;HPDL;HYKK;IRF1;

ITGA6;KLK3;KRAS;LAMA5;LMTK2;MAP2K7;MAP4K2;MAX;MEN1;MIR5580;MITF;MLH1;

MLH3;MLPH;MSH2;MSH6;MSMB;MSR1;MTAP;MT-ND3;MUTYH;MXl1;NF1;NUDT11;PADl6;

PALB2;PCAT2;PDLIM5;PIGU;PMS2;POU5F1B;PTEN;RAD51;RAD54B;RAD54L;RB1;RET;

RFX6;RHPN2;RNA5SP299;RNASEL;RNU1-19P;RRAS2;RUNX1;SDHB;SDHC;SDHD;

SLC22A3;SMAD4;SMAD7;STK11 ;TERT;THADA;TMEM127;TP53;TP63;TSC1 ;TUBB3;VHL;

WEE1 ;XRCC1 ;XXYLT1


Billing ABN and Patient Plan Information: A completed Advance Beneficiary Notice (ABN) of coverage

is required for Medicare patients who do not meet medical criteria for testing. This does not apply to specific

site analyses. Insurance pre-qualification will not be performed for these tests, unless specifically requested.

All tests ordered shall be processed and billed based on payor.


give my designated insurance carrier(s) plan on this form and other informabon provided by my health care

provider necessary for reimbursement. I authorize Novomed Specialized Clinics to inform my Plan of my

test results only if test results are required for preauthorizabon of or payment for reflex/additional testing.



responsibility concerning payment for laboratory services and that I am financially responsible for all

charges whether or not they are covered by my insurance. I understand that any payment I receive for

services rendered by the laboratory from my insurance provider should be forwarded immediately to the

laboratory.

The data may also reveal secondary or incidental findings, such as that you may be at risk for certain

genebc diseases or that you are a carrier of disease associated mutations.

Patient Consent: My signature below consrnutes my acknowledgment that the benefits, risks, and

limnations of this testing have been explained to my satisfaction by a qualified health professional and






Personal information will not be shared and will be kept confidenbal by Novomed Specialized Clinics.

If Signature is other than patent's. Printed Name ________________ _

This test is medically necessary for the diagnosis or detection of a disease, illness, impairment, syndrome

or disorder, and these results will be used in the medical management and treatment for this patient.

Furthermore, recipients' information is true and correct to the best of my knowledge.

The person listed as the Ordering Physician or genebc counselor is authorized by law to order the test(s)

requested herein. I confirm that I have provided genetic tesbng informabon to the patient and they have

consented to genetic testing.

Please check all that apply:

□ I confirm that the above patient's gene testing is medically necessary and the result will be used

to assess pabent for Mure cancer risk.

□ I agree to allow Novomed Specialized Clinics to transfer the information contained in this requisition

to an LMN (Letter of Medical Necessity) using the ordering physician's name as his/her signature

for insurance billing purposes.


D Patient meets clinical/genetic tesbng criteria for the above ordered tests.



D Copy of Patient Demographics Collected by: i:

D Current Meds List

D ICD-10 Diagnosis Codes

Print Name

D Patient's/Provider's Signatures

i1_

D Copy of Insurance Card (Front/Back)

a:

PATIENT'S OR RESPONSIBLE PARTY'S SIGNATURE DATE O Attach Patient's HG Insurance Pre-Authorizaton Form Sgnature c'j

,__________________________________ _.__________________________________ _,I



DATE

noven,ed

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PHARMACOGENETIC TESTING

Date: ________ _ Patient Name: _______________________ _

DOB: _______ _ Gender: □ M □ F

Insurance Company:, _____________________ _

Subscriber Name: ______________________ _

Policy#: __________________________ _


I am writing this letter on behalf of my patient, ------------------ to request coverage for the

Pharmacogenetic testing offered through Novomed Specialized Clinics. The Pharmacogenetic testing is performed in a high

complexity CUA certified laboratory located in Frisco, Texas.

My patient has not reached their therapeutic goal on the current regimen and may be experiencing adverse drug reaction(s)

to one or more medications. I am seeking to choose safer or more efficacious dosages. I request coverage for DNA

microarray and PCR analysis of targeted genes to identify genetic variants. This knowledge will help avoid

harmful and costly adverse drug events, optimize medication dose, and increase chances of patient's treatment success.


The pharmacogenetics panel offered by Novomed Specialized Clinics targets genes that when mutated are known to

impact patient's response to medication.

The result of this pharmacogenetic testing will have a direct impact on this patient's medication management.

Genetics account for much of the variability seen in our patients' responses to drug therapies and the implications of

pharmacogenetics have been well documented. Currently there are at least 230 U.S. Food and Drug Administration (FDA)

approved drugs with Pharmacogenomic information in their labeling. The labeling for some of the products includes specific

actions to be taken based on the biomarker information. In order to choose the more suitable medication and avoid potential

but serious adverse drug events, it is extremely important to perform this panel of Pharmacogenetic tests.

Patient's personal and/or family history as well as current medication regimen are suggestive of high risk for adverse drug

events based on my evaluation and review of latest available literature. In this patient's case, pharmacogenetics testing is

crucial in order to establish and confirm a genetic diagnosis, guide appropriate and immediate medical management,

predict disease prognosis, and eliminate potential adverse drug events.

Informed Consent:

The patient has provided a signed informed consent for pharmacogenetic testing, based on my discussion of the personal

and/or family history, the potential test results, and the implications for medical management. The patient is aware of the

benefits, risks, and limitations of the testing and has voluntarily agreed to the pharmacogenetic test.

Conclusion:

Knowledge of this patient's genetic information is important for me to accurately assess patient's medication regimen and

will guide my recommendations for treatment plan. I have chosen to send the patient's test to Ayass Lung Clinic, PLLC with

highly sensitive, rapid, and cost-effective pharmacogenetic which will provide helpful medical treatment planning information

for my patient.

Thank you for your review and consideration. I hope you will support this request for genetic testing coverage for my patient.

If you have questions, or if I can be of further assistance, please do not hesitate to call me at:

Sincerely,

Physician's Name: _________________________________________ _

Signature:----------------------------------------------



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Patient's Name

OM OF

Birth Date:

Date:








Date:

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If there are any questions about the results, do not hesitate to contact

us.

If follow-up tests and further additional tests are necessary at the Novomed Centers, the

reservation and further instruction will be informed.

Release of Medical records

For requesting medical records and image data (USB copy), please inform us before visiting to shorten the

waiting. Since referral letter and medical certificate need to be filled out by the attending physician,

please make a request by phone in advance.

Result

Consultation

Location :Suite 3004, 30th Floor | Marina Plaza | Dubai, UAE

Operation hours :Saturday-Wednesday: 9am-9pm | Thursday: 9am-6pm

Contact number:800 6686633

Body Composition Analysis 720

Height

Date/Time

50781450 48

170.6cm Male 21/06/2019

08:21:43(98480)

partments Values Total Body Water Soft Lean Mass Fat Free Mass Weight Normal Range

W 25.4

22.3~27.3

40.7

W 15.3

52.3

13.7~16.7

55.5

11.0

84.8 9.6~11.8

2

VFA (cm )

250

200

150

3.87

non osseous

osseous: 3.17

3.33~4.07

100

29.3

7.7~15.4

50

Mineral is estimated

0

20

40 60 80 Years

Under Normal Over

Unit %

Normal Range

55 70 85 100 115 130 145 160 175 190 205

70 80 90 100 110 120 130 140 150 160 170

54.4~73.6

27.3~33.4

Protien

Mineral

Fat

Normal

Normal

Normal

Deficlent

Deficlent

Deficlent

Excessive

40 60 80 100 160 220 280 340 400 460 520

7.7~15.4

Weignt Management

Weight Normal

Under

Over

Diagnosis

Under

Normal

Over

Normal Range

SMM

Fat

Normal

Normal

Strong

Under

Under

Over

10 15 18.5 22 25 30 35 40 45 50 55

0 5 10 15 20 25 30 35 40 45 50

0.70 0.75 0.80 0.85 0.90 0.95 1.00 1.05 1.10 1.15 1.20

0.326

Date/Time Weight SMM Fat Score ECW/TBW

21/06/2019 84.8 31.1 29.3 62 0.376

08:21

18.5~25.0

Lean Lean/Ideal Lean x100 (%) Fat Mass

Under

Normal

Over Unit % Segmental Edema

Edema

ECF/TBF ECW/TBW ECF/TBF ECW/TBW

55 70 85 100 115 130 145 160

55 70 85 100 115 130 145 160

70 80 90 100 110 120 130 140

70 80 90 100 110 120 130 140

70 80 90 100 110 120 130 140

0.327

0.330

0.330

0.332

0.372

0.374

0.376

0.377

0.379

Segmental fat is estimated

10.0~20.0

0.80~0.90

0.41

0.38

0.35

0.33

0.31

0.28

0.25

0.330

0.46

0.43

0.40

0.38

0.36

0.33

0.30

0.376

Normal

Normal

WHR

Normal

Upper Balanced

Balanced

Balanced

Upper Normal

Normal

Muscle Normal

Health Diagnosis

Normal

Edema Normal

Normal

Weight Control

Target Weight

Weight Control

Fat Control

Muscle Control

Fitness Score

Under

Extremely Over

Over

Over

Slightly

Unbalanced

Slightly

Unbalanced

Slightly

Unbalanced

Developed

Developed

Developed

Under

Slight Edema

Over

Extremely

Over

Extremely

Over

Extremely

Unbalanced

Extremely

Unbalanced

Extremely

Unbalanced

Weak

Weak

Weak

Edema

Alert Risky

Highlu Risky

65.3 kg

_ 19.5 kg

_ 19.5 kg

0.0 kg

62

Points

Copyright C 1996-2005 by InBody Co.Ltd All rights reserved BR-ENG27 - B - 050530

Feel Free to download the U.S best seller E-booklet by Dr.

Max at https://www.novomed.com/food-habits/

Commitment Form – Result Consultation

This commitment form is to allow Healthcare System Novomed Centers to provide medical

information to the certain person mentioned below. Novomed Centers will never provide your medical

check up results and consultation information to a third party except the person below. If the

results are disclosed or destroyed due to any other reasons below, Novomed Centers shall not be

a. The result incurred due to your negligence in management.

b. Unavoidable circumstance such as natural disasters.

I or (testee), the undersigned, hereby make, constitute, and appoint

Name:

Address:

Tel:

Relationship:

As my true and lawful attorney, with full power and authority to have the test results (Date of

examination (MM/DD/YY): / /20 ; Form as printed version and USB copy)

and medical consultation with one of the center’s physician.

Date: / / 20 (MM/DD/YY)

Testee (or Guardian)

Signature

If you are not the testee yourself, please fill out the following questions.

Relationship with testee:

Address:

Residence ID number:

Phone number:

This request is valid with the testee’s signature or seal, but if the testee is a minor or with

Any and all legal hearings will only be tried under the jurisdiction of UAE law.

Suite 3002 – 300 th Floor, Marina Plaza,Dubai Marina, Dubai, UAE

800 NOVOMED (668 6633) @novomedcenters www.novomed.com

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