Last modified: December 2, 2025
Requisition forms | DUTCH
Patients
Tip!
This guide walks you through completing your DUTCH requisition form. For other lab requisition guides, see Filling out requisition forms and activating kits.
Each DUTCH test has a unique two-page requisition form, but most require the same set of details. This guide outlines the fields you’ll complete and highlights any differences between certain tests.
Sample DUTCH requisition form
Note:
Fields in red boxes will come pre-filled. You’ll need to complete all other areas on both pages when you collect your sample.
Sample DUTCH requisition form, front page
Sample DUTCH requisition form, back page
Required fields for all DUTCH tests
The following information is required for all DUTCH tests:
- Ethnicity
- Sample collection dates and times
- If applicable, Women-only section
- Hormone, supplement, and prescription information
- Disease states and fatigue
- Current or recent medical diagnoses not already listed on the form
- Symptom ratings and additional symptoms
- Weight category (e.g. underweight, ideal weight, overweight)
- Health goals or concerns related to the test
- Any other medications or supplements you’re currently taking
Additional fields for certain DUTCH tests
The DUTCH Cycle Mapping and DUTCH Cycle Mapping Plus tests have additional required fields:
- Additional cycle information: start date and typical length
- Birth control history