P.O. Box 6101
Newark, Delaware 19714-6101
Call toll-free: 1-800-242-3233,
option 3, option 2

First Name:	Last Name:
Title:	Institution:
Address:
City:	State/Province:
Country:	Postal Code:
E-mail Address:	Phone Number:

Profession:

Physician
Nurse
Dietitian
Medical Technologist / Laboratorian
Manager
Pharmacist
Administration
Other, please specify:

Board Certification (if applicable)

Age:

Sex: M F

Institutional Affiliation:

Community Hospital
Teaching Hospital
VA Hospital
Other, please specify:

Location:

Large Metropolitan Area
Large City
Medium City
Small City
Rural

Please indicate the status of your institution's nutrition support program:

Nonexistent
Poor
Poor, but improving
Good/Excellent

Please indicate if your institution regularly performs:

Pre-admission nutrition screening

Triage of incoming patients based on screening

Regular assessment of all inpatients
How often?

Regular assessment of at-risk patients only
How often?

Please describe your use of Plasma Protein markers for nutritional assessment.
(Click the markers you use and the situations in which the markers are utilized.)

Marker	Pre-admission Screening/Triage	Regular assessment of at-risk patients	Regular assessment of all patients	As needed only
Albumin
Prealbumin
Transferrin
Retinol-Binding Protein
C-Reactive Protein
a1-Acid Glycoprotein

Comments:

I would like to submit a question/comment.

I would like to submit a case study for inclusion in the Diagnostic Challenge section.

	I would like to comment on the general quality and/or content of the Nutrition Perspectives^® site.

I would like to see the following issue(s) addressed in the site.

I would like to receive a copy of the Nutritional Assessment: The Key To Well-Nourished Outcomes monograph.

I would like more information on the following Siemens Healthcare Diagnostics instruments:

Siemens Nephelometers
(i.e., BN™II, BN™100, BN ProSpec^®)

Dimension^® RxL System

Other, please specify:

I would like more information on Siemens Plasma Protein markers.