Tiana Rockwell, NTP
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Nutrition Testing request Form
Please complete the following form for any of the following tests. All tests include a report of findings consultation to help you make any suggested changes to improve your health. Once the form has been submitted and payment for the test has been made, an email with further instructions on how to complete the test will be sent to you.
Comprehensive Stool Test:
The Comprehensive Stool Analysis detects the presence of pathogenic microorganisms such as yeast, parasites, and bacteria that contribute to chronic illness and neurological dysfunction. It provides helpful information about prescription and natural products effective against specific strains detected in the sample. The test also evaluates beneficial bacteria levels, intestinal immune function, overall intestinal health, and inflammation markers. Read more
Food Sensitivity Test:
An innovative tool that tests IgG & IgA reactivity to 96 most commonly consumed foods including Dairy, Meat, Seafood, Fruits, Vegetables, Grains, Legumes, Nuts and Nightshades amongst others. Read more
1 in 7 Americans suffers from some type of wheat and/or gluten sensitivity. This test is a health analytics tool built to assist in the detection of wheat and gluten-related disorders. It aids in the specific recognition of antibodies to wheat peptides-including gluten and non-gluten components along with intestinal permeability and genetic predisposition to celiac disease. Read more
The only test that provides a comprehensive extracellular and intracellular assessment of the levels of the most important vitamins, minerals, antioxidants, fatty acids and amino acids. Knowing both your extracellular and intracellular micronutrient levels are key to a thorough understanding of your nutritional requirements at a foundational level, which may contribute to your risk for disease, while simultaneously and positively impacting your overall health and well-being. Read more
Organic Acids Test (OAT):
A comprehensive metabolic snapshot of overall health with over 70 markers. It provides an accurate evaluation of intestinal yeast and bacteria (which can cause or worsen behavior disorders, hyperactivity, movement disorders, fatigue and immune function). This test also includes markers for vitamin and mineral levels, oxidative stress, neurotransmitter levels, and is the only OAT to include markers for oxalates, which are highly correlated with many chronic illnesses. Read more
GPL-TOX Profile (toxic non-metal chemicals):
Because exposure to environmental pollutants has been linked to many chronic diseases, The Great Plains Laboratory has created GPL-TOX, a toxic non-metal chemical profile that screens for the presence of 172 different toxic chemicals including organophosphate pesticides, phthalates, benzene, xylene, vinyl chloride, pyrethroid insecticides, acrylamide, perchlorate, diphenyl phosphate, ethylene oxide, acrylonitrile, and more. This profile also includes Tiglylglycine (TG), a marker for mitochondrial disorders resulting from mutations of mitochondrial DNA. These mutations can be caused by exposure to toxic chemicals, infections, inflammation, and nutritional deficiencies. Read more
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Name (as it appears on your ID)
Address (as it appears on your ID)
Date of Birth (MONTH)
Date of Birth (DAY)
Date of Birth (YEAR)
Current Health Concerns
Current List of Medications/Supplements
Please list brand name, quantity taken, and frequency taken.
Please read the following waiver, consent and disclaimer carefully.
The laboratory services are for informational purposes only. It is not the intention of Tiana Rockwell, NTP to provide specific medical advice but rather to provide clients with information to better understand their health. Specific medical advice including diagnosis and treatment will not be provided. The test results are subject to the same privacy and release restrictions that HIPAA (The Health Insurance Portability and Accountability Act of 1996) places on all medical records. The HIPAA Privacy Rule, protects the privacy of individually identifiable health information. Clients should be aware that test results will not automatically be forwarded to your physician or become a part of office medical records unless you make a specific request. Clients may request to release information to their physician, if they desire. Always seek the advice of a trained health professional for medical advice, diagnosis or treatment.
NUTRITIONAL THERAPY INFORMED CONSENT AND DISCLAIMER
Before you choose to use the serviced of a certified nutritional therapy practitioner, please read the following information FULLY AND CAREFULLY.
Our basic goal is to encourage people to become knowledgeable about and responsible for their own health, and to bring it to a personal optimum level. Nutritional therapy is designed to improve your health, but is not designed to treat any specific disease or medical condition. Reaching the goal of optimum health, absent other non-nutritional complicating factors, requires a sincere commitment from you, possible lifestyle changes, and a positive attitude. A Nutritional Therapist is trained to evaluate your nutritional needs and make recommendations of dietary change and nutritional supplements. A Nutritional Therapist is not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis. Since every human being is unique, we cannot guarantee any specific result from our programs.
If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. A Nutritional Therapist is not a substitute for your family physician or other appropriate healthcare provider. A Nutritional Therapist is not trained nor licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases. If you are under the care of another healthcare provider, it is important that you contact your other healthcare provider and alert them to your use of nutritional supplements. Nutritional therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program.
If you are using medications of any kind, you are required to alert me, your nutritional therapist, to such use, as well as to discuss any potential interactions between medications and nutritional products with your pharmacist.
If you have any physical or emotional reaction to nutritional therapy, discontinue their use immediately, and contact me, your nutritional therapist, to ascertain if the reaction is adverse or an indication of the natural course of the body’s adjustment to the therapy.
Every client is an individual. And it is not possible to determine in advance how your system will react to the supplements you need. It is sometimes necessary to adjust your program as we proceed until your body can begin to properly accept products geared to correct the imbalance. It is your responsibility to do your part by using your nutrition guidelines, exercise your body and mind sufficiently to bring your emotions into a positive balance, eat a proper diet, get plenty of rest, and learn about nutrition. You must stay in contact with me, your nutritional therapist, so I can let you know what is happening and the best course of action. You should request your other healthcare provider, if any, to feel free to contact me for answers to any questions they may have regarding nutritionally therapy.
A Nutritional Therapist is not a licensed profession by any state. However, a certified Nutritional Therapy Practitioner is trained by the Nutritional Therapy Association, Inc. ® which provides a certification of completion to students who have successfully met all course requirements, including a written and practical examination. A license to practice Nutritional Therapy is not required in the state of California.
Nutritional Therapy may not be covered by insurance and all costs are the responsibility of the client.
By checking the box below, you agree to having read and understood the agreements and waivers
I agree to the Laboratory Waiver
I agree to the Nutritional Therapy Concent and Disclaimer
Must be 18 years or older to request labs
I am currently 18 years or older
By entering my name below, I assert that I have reviewed and agree to all of the waivers and agreements I have selected above.
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1020 Whispering Pines Lane, Suite D
Grass Valley, CA