Longevity Questionnaire

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone
FAX
E-mail

  How would you rate your overall health?

Good
O.K.
Poor

  Do you sense a general, steady decline in your ability
  to live a healthy, energetic, and vibrant life?

Yes    No

  Are you putting on weight you can't seem to get off?

Yes    No
 

  Is your thinking confused of "fuzzy"?

Yes    No

  How would you rate your skin?

Beautiful
So-so
Damaged/Aged

  How are your teeth?

Good
Periodontal Disease
Losing them

  Have you a sex life?

Satisfactory
Fading
You're got to be kidding

  Have you been diagnosed with Diabetes II?

Yes    No

  Do you think your immune system has been compromised?

Yes    No

  Were you aware that your internal organs shrink as you age?

Yes    No

  Do you have insomnia?

Yes    No

  Are your joints functioning smoothly?

Yes    No

  Do you have gout or a tendency to gout?

Yes    No

  Do you have digestive problems?

Yes    No

  Are you constipated?

Yes    No

  How is your eyesight?

Fine
Fading
Serious problems

  Are you under a great deal of stress?

Yes    No

  Do you have heart or circulatory problems?

Yes    No