Patient Recommendation Form

Name:

Baseline Test Test #2 Test #3

Date: (#1)

Revelar Score
Overall Free Radical Damage Assessment High / Low High / Low High / Low

Diet Recommendations
Fast Food

Processed sugar

Consumption of natural fruits/vegetables rich in color

Natural Antioxidants

Exercise Regimen Recommendations

Exercise activities

Aerobic Exercise

Anaerobic Exercise

Stress Levels and Reduction Recommendations

Activities

Other Modifications

Antioxidant Supplement Recommendations

Daily N Acetyl Cysteine

Daily Vitamin C

Daily Vitamin E

Daily Co-Q10, or ubiquinone

Daily Selenium

Other Antioxidant Supplements

Other Recommendations:

© 2010 Pulse Health LLC