Health Questionnaire and Testing Consent Form_Online

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.
Date

MonthDayYear
Client Information
Name*
Email*

Confirmation Email
Telephone Number*
Telephone Type*
Address*

Street Address

Street Address Line 2 (Apt/Unit/Building)

CityState

Zip Code
Age*
Date of Birth*

MonthDayYear
Sex*
Height in Inches*
Weight in Pounds*
Waist Circumference in Inches*
Race*

White/Caucasian/Non-HispanicBlack/African AmericanHispanic/LatinoAsianAmerican Indian/Alaskan NativeOther
Living Arrangement*

Live with othersLive alone
Marital Status*

SingleMarriedSeparated or Divorced
Education: Number of Years*
Education: Highest Level Attained*
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?*

YesNo
Have you had heart bypass surgery, angioplasty, or carotid or femoral artery surgery?*

YesNo
Have you had a stroke?*

YesNo
Have you had transient ischemic attacks?*

YesNo
Do you have a history of high blood pressure?*

YesNo
Are you taking medication for high blood pressure?*

YesNo
What was your most recent systolic blood pressure in mmHg?*
What was your most recent diastolic blood pressure in mmHg?
Do you have a history of diabetes?*

YesNo
Are you taking medication for diabetes?*

YesNo
Are you taking insulin?*

YesNo
Are you currently smoking cigarettes?*

YesNo
Do you have a history of high blood cholesterol?*

YesNo
Are you taking medication for high blood cholesterol levels?*

YesNo
Are you taking a statin?*

YesNo
If you are taking a statin, which statin and what dose?
Are you taking fish oil capsules?*

YesNo
If you are taking fish oil capsules, how many capsules are you taking daily?
Are you taking ezetimibe?*

YesNo
Do you have a history of liver disease?*

YesNo
Do you have a history of kidney disease?*

YesNo
Do you have a history of thyroid disease?*

YesNo
If you have a history of thyroid disease, are you taking thyroid hormone replacement?

YesNo
Do you have a history of depression?*

YesNo
Have you experienced memory loss or cognitive decline?*

YesNo
Did either of your parents have dementia?*

YesNo
Have you had any type of cancer?*

YesNo
If yes, what type of cancer?
Have you ever had an attack of gout?*

YesNo
Do you take medicine for gout?*

YesNo
Have you ever had anemia?*

YesNo
Do you take aspirin daily?*

YesNo
Do you take coumadin, Eliquis, or another anticoagulant?*

YesNo
Do you take clopidogrel?*

YesNo
Do you take a daily vitamin supplement?*

YesNo
Do you take vitamin D daily?*

YesNo
Do you take a daily calcium supplement?*

YesNo
Do you take a B vitamin supplement every day?*

YesNo
Do you take a folate supplement every day?*

YesNo
Are you taking any medications or supplements other than those mentioned in the questions above?*

YesNo
If yes, please list the other medications and supplements below.
Have you had any chronic disease that is not mentioned above?*

YesNo
If yes, please list the other chronic disease(s) you have had.
Acknowledgment, Authorization and Waiver
Please authorize the laboratory testing by agreeing to the following statements:*

I request and authorize Longevity Diagnostics and its collaborative laboratories Quest Diagnostics and Boston Heart Diagnostics to perform the health testing I have purchased on my blood or buccal swab specimen.I confirm that I am voluntarily purchasing this testing from Longevity Diagnostics.I understand that the results of the laboratory tests performed by Quest Diagnostics and/or Boston Heart Diagnostics will be confidentially reported to Longevity Diagnostics and that this information will be held confidential except as required by law.I understand that if I have purchased the Standard Health Test, the Advanced Health Test, or the Advanced Plus Health Test, I am to fast for at least 8 hours before having my blood drawn. That is, I will have nothing to eat or drink except for water or black, sugarless coffee or tea without dairy, non-diary, or sugar products added.I understand that fasting is not required if I have purchased the Longevity Genetics Test.I understand, if I am purchasing the Standard or Advanced Health Test, that my purchase includes a 30-minute, one-on-one teleconference with a nutrition and lifestyle coach who is a registered dietitian, which I will schedule when I receive my test results. If I am purchasing the Longevity Advanced Health Test, I will also be able to schedule a 15-minute, one-on-one medical consultation with a licensed healthcare professional.I acknowledge that all information I have provided in this form is true and accurate.
Client Signature

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Date Signed

MonthDayYear
Payment

Longevity Diagnostics Testing (select only one test panel)*

Longevity Standard Test Panel 27 lab tests with 30-minute nutrition and lifestyle coaching teleconference

$249.00 Quantity

Longevity Advanced Test Panel37 lab tests with 30-minute nutrition and lifestyle coaching teleconference and 15-minute medical consultation (Includes Longevity Standard Test Panel)

$549.00 Quantity

Longevity Genetics Test Panel7 tests for genetic variants associated with cardiovascular disease and dementia risk and response to certain medications

$249.00 Quantity

Longevity Advanced Plus Test Panel44 lab chemistry and genetic tests with 30-minute nutrition and lifestyle coaching teleconference and 15-minute medical consultation (combines Longevity Advanced and Longevity Genetics Test Panels)

$699.00 Quantity

Total

$0.00

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Health Questionnaire and Testing Consent Form

Client Information

Health Questions

Acknowledgment, Authorization and Waiver

Payment