Health Questionnaire and Testing Consent
  • Health Questionnaire and Testing Consent Form

    Health Questionnaire and Testing Consent Form

  • Thank you for purchasing a Longevity Diagnostics Health Test Panel. To complete your purchase, please fill in the Client Information and Health Questionnaire below; then, read and accept the Privacy and Terms of Service Statements and submit the payment details. The client and health information you provide will allow us to assess your laboratory test results more accurately and calculate your risk for major disease like heart disease, dementia, and diabetes. Your payment will be processed when the questionnaire and consent form have been submitted.

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  • Client Information


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  • Format: (000) 000-0000.
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  • Race*
  • Living Arrangement*
  • Marital Status*

  • Health Questions

  • Your answers to these questions assist us in determining your longevity risk factors and help us to provide you with a better analysis of your longevity estimate and lifestyle recommendations. 

  • Have you had a heart attack?*
  • Have you had heart bypass surgery, angioplasty, or carotid or femoral artery surgery?*
  • Have you had a stroke?*
  • Have you had transient ischemic attacks?*
  • Do you have a history of high blood pressure?*
  • Are you taking medication for high blood pressure?*
  • Do you have a history of diabetes?*
  • Are you taking medication for diabetes?*
  • Are you taking insulin?*
  • Are you currently smoking cigarettes?*
  • Do you have a history of high blood cholesterol?*
  • Are you taking medication for high blood cholesterol levels?*
  • Are you taking a statin?*
  • Are you taking fish oil capsules?*
  • Are you taking ezetimibe?*
  • Do you have a history of liver disease?*
  • Do you have a history of kidney disease?*
  • Do you have a history of thyroid disease?*
  • If you have a history of thyroid disease, are you taking thyroid hormone replacement?
  • Do you have a history of depression?*
  • Have you experienced memory loss or cognitive decline?*
  • Did either of your parents have dementia?*
  • Have you had any type of cancer?*
  • Have you ever had an attack of gout?*
  • Do you take medicine for gout?*
  • Have you ever had anemia?*
  • Do you take aspirin daily?*
  • Do you take coumadin, Eliquis, or another anticoagulant?*
  • Do you take clopidogrel?*
  • Do you take a daily vitamin supplement?*
  • Do you take vitamin D daily?*
  • Do you take a daily calcium supplement?*
  • Do you take a B vitamin supplement every day?*
  • Do you take a folate supplement every day?*
  • Are you taking any medications or supplements other than those mentioned in the questions above?*
  • Have you had any chronic disease that is not mentioned above?*

  • Acknowledgment, Authorization and Waiver

  • Please authorize the laboratory testing by agreeing to the following statements:*
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  • Payment

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