Longevity Intake Form
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
What is your height?
What is your weight?
Contact Number
Email Address
example@example.com
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
High Cholesterol
Other
How many hours of sleep do you get most nights of the week?
Do you ever work 3rd shift?
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Are you currently taking any medication?
Yes
No
Are you currently on a depression or anxiety medication (SSRI, SNRI, MAOI)?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Are you interested in losing weight?
yes
no
Do you have a history of cancer?
Please Select
Yes
No
What type of cancer? What was your treatment? Who was your Doctor?
Submit
Should be Empty: