What is your PearlMD Ageless Score
Take our 5 minute test to measure your Ageless Vitality?
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Full Name
First Name
Last Name
Gender
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Female
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Area Code
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Back
Begin
Your Health and Aging Profile
Height
Weight
Please rate yourself on a Scale of 1 to 10
(1=very low, 10= very high)
How do you rate your current level of health
*
How do you rate your current level of energy or vitality
*
How do you rate your short term memory or recall?
*
How restorative or restful is your sleep?
*
How do you rate your muscular strength (such as your grip strength)?
*
Do you consider yourself to look young for your age (10= very young)?
*
How do you rate your current stress levels
*
For Women: Do you have irregular periods or have you reached your menopause?
*
Please Select
No
Yes
For Men: Do you experience erectile dysfunction?
*
Please Select
No
Yes
Do you have high blood pressure or high blood sugar?
*
Yes
No
Do you have trouble falling asleep or staying asleep?
*
Yes
No
Do you feel isolated or alone?
*
Please Select
Yes
No
Please list any medications you are currently taking (e.g. warfarin, contraceptives, laxatives)
Please list any supplements you are currently taking
What are YOUR health care goals? (check all that apply)
*
Hormone Health
Performance or Energy
Disease Prevention
Aging well/Longevity
Gut Health/Digestive Support
Cognitive: Memory, Mental Sharpness
Emotional Wellbeing
Stress Management
Diet and Lifestyle Management
Weight loss, Metabolic Health
Skin Health, Appearance
Hair Health, Hair Renewal
Body Shaping,
Other
Please share any additional information
Back
Next
Your Lifestyle Profile
How often do you eat after 8pm at night?
*
Since the age of 30, have you gained more than 30lb or do you weigh more than 20% of your baseline weight at age 30 years?:
*
Please Select
No
Yes
How do you rate your current level of fitness?
*
Do you exercise?
*
Never
1-2 times a week
3-4 times a week
more than 4x a week
Do you smoke or vape?
*
Please Select
Yes-daily
Yes-weekly
Yes-rarely
No
How many per wk?
Back
Next
Family History and Chronic Disease Risk
Do you have a family history in an immediate relative (parent, grandparent or sibling) of any of the following? (check all that apply)
*
Heart Disease
Diabetes Mellitus
Stroke
Dementia
Osteoporosis
Cancer
Other
Please share any additional information below.
*
We will contact you to review your Ageless score and discuss options. Please provide your preferred date and time for a call and best contact tel #.
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