- longevity

Please provide the following information to help us understand your current health status and lifestyle, so we can better assist you in your journey towards improved longevity and overall well-being.

1. Personal Information

Full Name:

Email Address:

Date of Birth:

Gender:

Current Weight (kg):

Height (cm):

2. Your Goals

What are your primary health and longevity goals? (e.g., increased energy, disease prevention, improved fitness, weight management)

What motivates you to achieve these goals?

What challenges do you anticipate in reaching your goals?

3. Complete Medical Case History

Do you have any pre-existing medical conditions? (e.g., Diabetes, Hypertension, Heart Disease)

Please describe any significant medical conditions in your immediate family (parents, siblings, grandparents):

List any prescription medications you are currently taking:

List any supplements you are currently taking:

Have you had any of the following recent blood tests?

Blood Pressure

Cholesterol Panel

Blood Sugar (HbA1c/Fasting Glucose)

Vitamin D

Thyroid Panel

CRP (Inflammation)

Other (Please specify below)

Musculoskeletal Health & Pain History

Do you currently experience any chronic pain? If yes, please describe its location, intensity (1-10), and how long you’ve had it.

Have you had any significant injuries or operations in the past? If yes, please describe.

Do you have any diagnosed musculoskeletal conditions (e.g., arthritis, osteoporosis, disc issues)?

How do musculoskeletal issues or pain affect your daily activities and quality of life?

4. Lifestyle Habits

Smoking Status:

Current Smoker

Former Smoker

Never Smoked

Alcohol Consumption (drinks per week):

Stress Levels (1 = Low, 5 = High): 3

How often do you socialize with friends/family?

List any hobbies or interests you regularly engage in:

5. Diet & Nutrition

What best describes your typical diet?

How often do you consume processed foods (e.g., fast food, sugary snacks, pre-packaged meals)?

How many servings of fruits and vegetables do you typically eat per day?

Average daily water intake (liters):

Do you have any food allergies or sensitivities?

6. Exercise & Physical Activity

How many days per week do you typically exercise?

What types of exercise do you engage in?

Cardio (e.g., running, swimming)

Strength Training (e.g., weights, bodyweight)

Flexibility (e.g., yoga, stretching)

Sports

Other (Please specify)

Average duration of each exercise session (minutes):

Average hours per day spent sitting or being sedentary:

7. Sleep Habits

Average hours of sleep per night:

Overall sleep quality (1 = Very Poor, 5 = Excellent): 3

Do you experience any sleep disturbances (e.g., insomnia, snoring, waking up frequently)?

8. Mental & Emotional Health

How would you generally describe your mood?

How do you typically cope with stress or difficult emotions?

Do you practice mindfulness or meditation?

Yes, regularly

Sometimes

Do you feel a strong sense of purpose or meaning in your life?

longevity

Longevity & Health Questionnaire