Life Expectancy and Lifestyle Questionnaire
Complete all sections with your demographics, health conditions, daily functioning, and lifestyle details to generate an individualized estimate.
Core Demographics
Name
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Sex assigned at birth
*
Male
Female
Height (in)
*
Weight (lb)
*
BMI
Highest level of education completed
*
Please Select
Less than high school
High school
Some college
College degree or higher
Current living situation
*
Independent home
With family/caregiver
Assisted living
Nursing home
Hospital
Comorbidity Burden
Diabetes
*
Present
Absent
Notes / severity for Diabetes
Approximate year of diagnosis for Diabetes
High blood pressure
*
Present
Absent
Approximate year of diagnosis for High blood pressure
Notes / severity for High blood pressure
Coronary artery disease / prior heart attack
*
Present
Absent
Notes / severity for Coronary artery disease / prior heart attack
Approximate year of diagnosis for Coronary artery disease / prior heart attack
Heart failure
*
Present
Absent
Approximate year of diagnosis for Heart failure
NYHA class / notes for Heart failure
Stroke or TIA
*
Present
Absent
Approximate year of diagnosis for Stroke or TIA
COPD / emphysema
*
Present
Absent
Approximate year of diagnosis for COPD / emphysema
On oxygen?
No
Yes
Asthma
*
Present
Absent
Approximate year of diagnosis for Asthma
Notes / severity for Asthma
Chronic kidney disease
*
Present
Absent
Approximate year of diagnosis for Chronic kidney disease
On dialysis?
No
Yes
Liver disease / cirrhosis
*
Present
Absent
Approximate year of diagnosis for Liver disease / cirrhosis
Notes / severity for Liver disease / cirrhosis
Cancer
*
Present
Absent
Approximate year of diagnosis for Cancer
Cancer type
Active or metastatic?
No
Yes
Dementia / cognitive impairment
*
Present
Absent
Approximate year of diagnosis for Dementia / cognitive impairment
Notes / severity for Dementia / cognitive impairment
Parkinson disease
*
Present
Absent
Approximate year of diagnosis for Parkinson disease
Notes / severity for Parkinson disease
Depression or other mental illness
*
Present
Absent
Approximate year of diagnosis for Depression or other mental illness
Notes / severity for Depression or other mental illness
Arthritis / chronic pain
*
Present
Absent
Approximate year of diagnosis for Arthritis / chronic pain
Notes / severity for Arthritis / chronic pain
Other condition
Total number of prescription medications taken daily
*
Hospitalizations in the past 12 months
*
No
Yes
If yes, how many hospitalizations in the past 12 months?
Functional Status
ADLs
*
Rows
Independent
Needs some help
Fully dependent
Bathing
Dressing
Toileting
Transferring (bed/chair)
Feeding
Walking across a room
IADLs
*
Rows
Independent
Needs some help
Fully dependent
Cooking / preparing meals
Managing finances
Managing medications
Shopping
Using transportation
Housework
Falls in the past year
*
No
Yes
Number of falls in the past year
Falls-related injury in the past year
*
No
Yes
Walking aid
*
None
Cane
Walker
Wheelchair
How fast can you walk 4 feet?
*
Assistive device used for walking speed test
No
Yes
Longest distance walked without stopping (ft)
*
Frailty and Self-Rated Health
General health rating
*
Excellent
Very good
Good
Fair
Poor
How would you rate your hearing, on a scale from 1-10 (10 being stellar)?
*
How would you rate your eyesight (with correction, if applicable), on a scale from 1-10 (10 being stellar)?
*
How would you rate your sleep quality, on a scale from 1-10 (10 being stellar)?
*
How would you rate your social network, on a scale from 1-10 (10 being stellar)?
*
How would you rate your participation in leisure activity, on a scale from 1-10 (10 being stellar)?
*
How would you rate your psychological well-being, on a scale from 1-10 (10 being stellar)?
*
How would you rate your stress level, on a scale from 1-10 (10 being the worst)?
*
Unintentionally lost more than 10 lb in the past year?
*
No
Yes
How many?
Often feel exhausted or that everything is an effort?
*
No
Yes
Lifestyle and Behavioral Factors
How would you rate your diet quality
*
Poor
Fair
Good
Excellent
How many sugar-sweetened beverages (including juice) do you consume each week?
*
How many servings of whole fruits do you consume on average per day?
*
How many servings of whole vegetables do you consume on average per day?
*
How many servings of whole grains do you consume on average per day?
*
How many servings of nuts or seeds do you consume on average per day?
*
How many servings of legumes (things that come in a pod - beans, peas, peanuts) do you consume on average per day?
*
How many servings of fatty seafood (salmon, tuna, trout, mackerel, sardines, anchovies) do you consume on average per week?
*
Compared with a year ago, physical activity is
*
More
Same
Less
How many minutes a week on average to you participate in aerobic (cardiovascular) exercise?
*
How many days per week on average to you participate in resistance (strength-building) exercise?
*
Smoking status
*
Never
Former
Current
Packs per day
How many years smoked
Pack-year history
Year quit
Alcohol use
*
None
Occasional
A few per week*
Several per week*
How many drinks per week and of what type?
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