NEUROMUSCULAR TEST PRESCRIPTION FORM 1


Motor Neuropathy - ALS

Antibodies (2 red-top tubes to IWJ - Room 404)
      [ ] GM1 ganglioside panel; [ ] GalNAc-GD1a ganglioside
Immunofixation
      [ ] Serum
      [ ] Urine
      [ ] Quantitative serum immunoglobulins
Metals: [ ] Serum lead;  [ ]  Urine heavy metal screen (random)
Metabolic:  [ ]  Hexosaminidase A&B; [ ]  Uroporphyrinogen-1-synthetase
      Alternate Tests (Porphyria)
      [ ] δ-Aminolevulinic acid & Porphobilinogen (24-hour urine)
      [ ] Schwartz-Watson (Send to lab in one hour)
Other___________________________________________________
      [ ] CBC; [ ] Basic metabolic panel; [ ] Sedimentation rate; [ ] C-reactive protein
      [ ] Immunocompetency panel (CD19 + other lymphocytes); [ ] Serum CK
      [ ] Muscle biopsy _______________; [ ] Nerve biopsy _______________; [ ] Vital capacity
EMG, NCV, Neuroimaging: Use separate requisition form

Sensory ± Motor Neuropathy

Diabetes: [ ] Hemoglobin A1C; [ ] Glucose tolerance test
Vitamin & Metabolic
      Vitamins: [ ] Vitamin B-12 and Folate; [ ] Vitamin E; [ ] Thiamine;[ ] Pyridoxine
                    [ ] Quantitative serum Methylmalonic acid & Homocysteine (Colorado)
      [ ] Lipid profile; [ ] Serum copper; [ ] α-galactosidase (Leukocyte)
Immunofixation (for M-proteins)
      [ ] Serum; [ ] Urine
      [ ] Quantitative serum immunoglobulins
Antibodies (2 red-top tubes to IWJ building - Room 404)
      [ ] Peripheral neuropathy screen
      [ ] MAG; [ ] Sulfatide; [ ] Heparan sulfate; [ ] AHS; [ ] Histone H3; [ ] TS-DS
      [ ] Demyelinating neuropathy: β-tubulin, GalNAc-GD1a & MAG
      Ataxia: [ ] GALOP syndrome Ab; [ ] GQ1b; [ ] Neurofilament
      Other antigens (IgM Ab):  [ ] GM2;  [ ] GD1a;  [ ] GD1b; [ ] asialo-GM1; [ ] Decorin; [ ] Chondroitin sulfate
      Cryoglobulin: [ ] Cryoglobulins; [ ] Hepatitis B surface antigen; [ ] Hepatitis C antibody; [ ] Rheumatoid factor
      Paraneoplastic (2 red-top tubes to IWJ  - Room 404): [ ] Anti-Hu (Neuronal nuclear antigen); [ ] Yo; [ ] Ri
      Connective tissue disease: [ ] ANA battery; [ ] ENA; [ ] Anti-neutrophil cytoplasmic (ANCA)
      Gluten enteropathy: [ ] Anti-Gliadin (IgG & IgA); [ ] Anti-Endomysial; [ ] HLA DQ2 & DQ8
Toxins: [ ] Blood lead; [ ] Urine for heavy metals
Other___________________________________________________
      [ ] Muscle biopsy ________________; [ ] Nerve biopsy ________________
Neuromuscular Division
Washington University
IWJ Room 404
Box 8111, Neurology
660 South Euclid Avenue
St. Louis, MO 63110
Phone: 314-362-6981
Fax: 314-362-3752
      [ ] Vital capacity; [ ] HDL cholesterol battery screening; [ ] Sedimentation rate
      [ ] Phytanic acid; [ ] Long chain fatty acids; [ ] Cerebellar immunostaining
EMG, NCV, Neuroimaging: Use separate requisition form

DATE:_____________PATIENT NAME:______________________________
ORDERING PHYSICIAN: Pestronk; Al-Lozi; Lopate; Connolly; Malone; Nozaki
          Other__________________________________________
SIGNATURE:_____________________________________________
DOB:______________ DIAGNOSIS:_________________________________

AP 11/7/2006