HealthRX.com · Printable lab tracker
Reverse triiodothyronine lab tracker for fasting and nutrition
Use this sheet to track reverse triiodothyronine results alongside fasting, very-low-calorie, low-carbohydrate and supplement periods. Bring it to your prescriber or pharmacist before a blood draw or medication review.
Lab order and result details
Copy these from your lab slip or report.
Date of reverse triiodothyronine blood drawWrite the date the sample was taken
Date the last fast or restricted diet endedWrite the calendar date, not a count of days
Reverse triiodothyronine resultCopy the value and unit exactly as printed
Reference interval printed on the reportCopy the low and high limits from the report
Free triiodothyronine resultCopy the value and unit as printed
Thyroid stimulating hormone resultCopy the value and unit as printed
Ordering clinician or lab nameWrite the name on the requisition
Before the blood draw
Confirm these with your clinician or lab.
- Confirm that reverse triiodothyronine is on the order as an add-on test
- Ask how long after a fast or very-low-calorie diet the draw should wait
- Note any supplements taken in the past weeks, including selenium, zinc, iron and iodine
- Bring the log below showing fasting, restriction and carbohydrate periods
- Check with your pharmacist whether any current medicine could affect thyroid tests
- Write down the time of day and whether you were fasting for the draw
Eating, fasting and symptom log
Record each day or fasting period as it happens.
| Date | Eating or fasting pattern | Total intake noted | Carbohydrate level | Symptoms noticed |
|---|---|---|---|---|
Questions for my prescriber or pharmacist
- Does my reverse triiodothyronine result fall within the lab reference interval?
- How does my free triiodothyronine to reverse triiodothyronine ratio compare with the target I was given?
- Should I wait before a repeat reverse triiodothyronine test after my fast or diet ended?
- Would my selenium, zinc, ferritin or iodine levels be checked before any change in plan?
- Could my current supplements affect these results?
- What symptoms should I track and report between visits?
- What would the next steps be if the result stays high after nutrition changes?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.