Your nutritional check-up

Answering this questionnaire may seem to take a long time and be a nuisance: but don't forget that it includes information used to precisely establish your nutritional and hormonal conditions and to set-up an exact, completely individual program to get you into top shape, now and for years to come. Your answers are completely confidential, and only used for your check-up and our specific proposal for supplements and optimizing your health and longevity. The complete interpretation of the check-up, biological tests and the detailed proposal for supplements is subject to conditions and payment (see the end of the questionnaire) They are not in any way to be used to make a medical diagnosis, which is something only your doctor is qualified to do. If you feel that certain questions are an infringement, of it you do not know how or want to answer them, let us know by e-mail : . We will either try to help you answer them (at no cost) . Or will will determine your check-up without these answers
Surname:
Name:
Profession:
Sex:	Male Female
Age:
Address:
City:
Country:
Postal code:
Home phone:
Work phone:
Fax:
E-Mail:


Why are you interested in consulting an anti-aging specialist?
What is your weight in the morning, undressed and without eating ?
What was your weight at age 18?
How tall are you (in centimeters)?
How tall were you at 18?
What is your waist measurement?
What is your hips measurement?
What blood type are you?



Do you regularly practice (at least twice a week) a moderate physical activity (walking, cycling, swimming, golf.)	Yes Rarely No
How long each time?	- than 20 Min 20 to 40 Min + than 40 Min
Do you regularly practice one or more sports or physical activities in an intensive manner (aerobics, squash, tennis, jogging...) ?	never rarely often jogging cycling swimming gym aerobics step rowing other
How long each time?	- than 20 Min 20 to 40 Min + than 40 Min
For how long?	-than 1 year from 1 to 3 years + than 3 years
What is your fastest heart rate during these activities?
Do you practice any relaxation technique or yoga?	yes no - than 2 times/week 2 to 4 times + than 4 times/week

TOBACCO:

Do you smoke?	Yes No Never smoked
If yes, how many cigarettes per day (or cigars or pipes)?	- than 5 5 to 10 10 to 20 + than 20
For how long?	- than 1 year from 1 to 5 years from 5 to 10 years + than 10 years
If you have quit smoking: for how long ?	- than 1 year from 1 to 5 years from 5 to 10 years + than 10 years
Does anyone in your family or at work smoke?	Yes No

ALCOHOL:

Do you drink alcohol or alcoholic beverages?	Yes No Never
If yes, how many glasses (wine glass) of wine per day?	- than 2 2 to 4 + than 4
and how many days/week?	- than 2 2 to 4 + than 4
If you drink other alcoholic beverages please specify :	beer pastis whisky vodka port other
The daily quantity in units:	1 to 2 3 to 4 + than 4
Frequency: (day/week)	- than 2 days/week from 2 to 4 days/week + than 4 days/week



Do you consider yourself happy?	Yes No Relatively Very
Does your job fulfil you ?	Yes No Relatively Very
On a scale of 1 to 10 what is your level of sexual satisfaction
Have you undergone a stressful event in the past year (death of a close family member/friend, dismissal from job, move, serious illness etc.)?	Yes No
Is your job in a polluted environment ?	Yes No I don't know
Are you or have you ever been in danger of occupational poisoning (jobs in metal processing, paints, handling of bonding agents, agricultural products, pottery etc.)?	Yes No I don't know
If yes, which?
How long do you sleep on average ?	- than 6 hours from 6 to 8 hours + than 8 hours
What is the quality of your sleep ?	- Good Fair Mediocre
Do you take sleeping pills or hypnotics?	Yes Regularly No Never
How many times a week?	- than 2 per week from 2 to 4 per week + than 4 per week
Since when?	- than 1 year from 1 to 5 years + than 5 years
Do you snore?	No Rarely Often Always
Do you wake up startled?	No Sometimes Often
Do you wake up tired?	Never Sometimes Often
How many vacations do you take per year?	No vacations - than 2 weeks between 2 and 4 weeks + than 4 weeks
Are you tired?	No Sometimes Often Always in the morning Late in the morning After lunch In the afternoon In the evening
Are you currently being treated for one or more illnesses? If so, for how long?	- than 1 year from 1 to 3 years + than 3 years Always
Please specify the type of illness:	Cardiovascular Rheumatic Psychiatric Allergies Tumor Immune system Neurological I don't know Other
How old are your living relatives, in particular?	Father: Mother: Brothers and Sisters: Grandparents: Aunts, Uncles:
what type of illness do your relatives have?	Cardiovascular Rheumatic Psychiatric Allergies Tumor Immune system Neurological Diabetes Other
Do you know the illnesses that other family members (grandparents, aunts, uncles, brothers and sisters) have had?	Cardiovascular Rheumatic Psychiatric Allergies Tumor Immune system Neurological Diabetes Other



Do you have an intellectual activity?	No Rarely Often Every day
Do you read?	No Rarely Often Every day
What type of reading ?	Magazine Novel Narrative Technical Professional Other
Do you easily remember what you read?	No Often Always
Do you suffer from "lapses of memory"?	No Sometimes Often Regularly
Do you remember recent or past events easily?	Yes No
Do you often look for your things?	No Sometimes Often Always
Do you not finish sentences ?	No Sometimes Often Always
How many telephone numbers do you know by heart ?	none - than 3 3 to 5 5 to 10 + than 10



Do you have a happy nature?	No Rarely Often Every day
A sad nature?	No Rarely Often Every day
Are you angry?	No Rarely Often Every day
Are you often nervous or anxious?	No Rarely Often Every day
Do you start projects?	No Rarely Often Every day
Do you cry when reading a book, watching a film or listening to music ?	No Rarely Often Every day
Do you take, or have you taken, anxiolytics, antidepressants, tranquillizers on a regular basis ?	Yes No
For how long ?	Recently 1 to 3 years + than 3 years
If you have quit, was it:	Recently 1 to 3 years + than 3 years



Do you systematically eat what is put in front of you at the table?	Yes No
Do you systematically eat whatever you crave ?	Yes No
Do you think about which foods are good for your health?	Yes No
Do you normally follow a diet? If yes, please specify:
How much fruit or fruit juice do you have per day ?	- than 1 1 to 3 years + than 3
How many vegetables (including in soups) do you have per day?	- than 1 1 to 3 years + than 3
Do you eat bread?	Yes No
White bread:	Yes No
Whole-wheat bread:	Yes No
Other Bread:	Yes No
Please give the daily quantity in grams:
How many meals do you normally eat in a day?	1 2 3 + than 3
What type of oil do you use to dress your salads ?	Olive Walnut Rapeseed Sunflower Soy Mix of olive and rapeseed Mix of olive and walnut Mix of olive and soy other mix
How much water do you drink a day ?
What kind of water?	Tap filtered tap mineral water in a plastic bottle mineral water in a glass bottle
How much total fluids do you think you drink in a day (including soup)?	- than 1 liter from 1 to 3 liters + than 3 liters
Do you eat breakfast?	Never Rarely Often Every day
What do you eat?
Do you eat lunch?	Never Rarely Often Every day
What do you eat?
Do you have 5 o'clock tea?	Never Rarely Often Every day
What do you eat?
Do you eat dinner?	Never Rarely Often Every day
What do you eat?
Do you drink sugary drinks or sodas, if yes, what?
How many times a week:
Do you eat meat?	Yes No White Red
How many times a week:	1 time 2 to 3 times + than 3 times
Do you eat fish?	Yes No
How many times a week:	1 time 2 to 3 times + than 3 times
If yes, please specify the fish you eat in decreasing order:
Do you eat cheese?	Yes No
Cow milk cheese, the number of times per week:	1 time 2 to 3 times + than 3 times

Goat milk cheese, the number of times per week:	1 time 2 to 3 times + than 3 times
Do you regularly eat yogurt?	Yes No Plain fruit-flavoured Skimmed Soy Goat or sheep milk
Do you regularly use butter?	Yes No
How much per day?
Do you regularly eat deli meats?	Yes No
Do you regularly eat eggs?	Yes No
How do you normally prepare your eggs?	soft boiled fried scrambled in an omelette one time/week 2 to 3 times/week + than 3 times/week
Do you have dessert other than fruit?	Yes No
How many times a week:	1 time 2 to 3 times + than 3 times
In general, which foods do you crave the most ?
Do you ever fast? if yes how many days a year?	a few days + than a week
Do you take any supplements (vitamins, minerals, anti-oxidants, fatty acids, herbs.), if yes, which, please add a complete list with brand names, formulas and number taken per day if possible:



Do you have or have you had palpitations ?	Never Rarely Often
What is your heart rate after resting (for at least 30 minutes)?	- 60 beats/minute between 60 and 80 beats/minute + than 80 beats/minute
Do you have chest pains ?	Never Rarely Often
Do you become breathless with physical exertion ?	Yes No
Do you know what your blood pressure is upon awakening?	Normal Too high Low I don't know
You resting blood pressure?	Normal Too high Low I don't know
Your blood pressure under stress?	Normal Too high Low I don't know
Have you seen a cardiologist?	Never - than 3 years + than 3 years
If yes, what were the test results:
Electrocardiogram (EKG):	Not done Normal Abnormal
Chest sonogram:<	Not done Normal Abnormal
Stress test	Not done Normal Abnormal
TEST YOUR HEART'S ADJUSTMENT TO EXERTION Check your resting heartbeat: - With your heels on the floor, touch your toes thirty times in forty-five seconds: - Check your heartbeat (pulse) as soon as you finish: - And again after one minute of rest : At the end of the stress: After one minute of rest:



Your fasting glucose level (sugar in the blood in grams/liter)? Is it:	Unknown Normal Insufficient High
Is your glycosylated hemoglobin (Hb A1) level?	Unknown Normal Insufficient High
Is your total cholesterol level?	Normal Insufficient High
Are there any diabetics in your family?	Yes No I don't know
If yes, how many :	1 2 to 3 + than 3
Are they overweight?	Yes No I don't know
Are they thin?	Yes No I don't know
Does anyone have heart problems in your family (angina, infarct, cerebrovascular disorders)?	Yes No I don't know
if yes, and if you can, please specify who and at what age:
Does anyone suffer from high blood pressure in your family?	Yes No I don't know
if yes, and if you can, please specify who and at what age:
Does anyone suffer from cancer in your family?	Yes No I don't know
If yes and if you can, please specify:
Please provide more details on your medical history (yours or family), if you know them:



Do you have aches and pains?	Never Sometimes Often Every day
In your joints?	Yes No
Stomach?	Yes No
Elsewhere?	Yes No
If so, please specify where and how
Have you ever had a low iron count ?	Yes No
Has anyone in your family suffered from dementia (Alzheimer's disease, or similar diseases)?	Yes No
specify who and at what age:
Does anyone suffer from Parkinson's disease in your family?	Yes No
specify who and at what age:
Do you not have the will to live?	Never Sometimes Often Always
Do you have dark thoughts?	Never Sometimes Often Always
Do you want to cry?	Never Sometimes Often Always
Are you sensitive to cold?	Yes No Rarely Always
Are you too hot ?	Yes No Rarely Always
Do you have trouble gaining weight?	Yes No
Are your hands and feet cold?	Yes No Rarely Always
Do you have dental problems?	Yes No
Do you have fillings?	One 2 to 3 from 4 to 6 + than 6 No
Do you have crowns?	One from 2 to 3 from 4 to 6 + than 6 No
Do you have dental implants?	One from 2 to 3 from 4 to 6 + than 6 No
Do you feel tired or pain after having a tooth removed, cavities filled or crowns?	Yes No
Is your skin generally: ?	Dry Oily
Do you scar easily?	Yes No
Do you have a burning sensation in your stomach?	Never Sometimes Often Always
Does your stomach bloat and do you have gas?	Yes No Rarely Often
Do you have liquid or loose bowel movements?	Never Sometimes Rarely Often Always
Are you constipated?	Never Sometimes Rarely Often Always
How much weight have you gained in the last five years?
How much weight have you lost in the last five years?



TEST FOR THE LOSS OF SKIN ELASTICITY shows the deterioration of subcutaneous conjunctive tissue related to the formation of wrinkles. This starts to appear around age forty-five but variation of more than 10% above or below are not unusual. To take this test, pinch the skin on the back of your hand, between the thumb and index finger and measure the time it takes for the crease to disappear.	How long did it take ?

GRADUATED RULER TEST measures your reaction capacity to an external stimulus. It is essential because your capacity to "survive in dangerous situations or an accident" depends on this ability which is affected by age. To take this test, ask someone to hold a flat wood 50 cm long ruler vertically by the upper end. Place the thumb and middle finger, spread 8 to 10 cm apart, at the same distance from the 50 graduation of the ruler. Ask the other person to let it go without warning and you need to try and grab the ruler. Your score is the graduation where you stopped the ruler. Do the test three times and take the average of the three scores.	What was your average ?

BALANCE TEST is a good test of the condition of your central and peripheral nervous system. This test needs to be done barefoot or in flat shoes, on the left leg if you are right-handed and on the right if you are left-handed. On a hard surface (not carpet or rug), put you feet together, close your eyes and left a foot 15 cm from the floor with your knee bent at a 45° angle. Try to stay on the other foot without moving and keeping your eyes closed. Ask another person to time how long you can stay like this. Take this test three times and take the average figure.	What is your average figure ?

VISUAL ACCOMMODATION TEST studies the adaptation capacity of the lens. The test can be used and interpreted no matter what type of vision you have because it is not the clearness of vision (astigmatism) it measures but the dynamic modification of vision based on distance. You do it without any type of glasses or with corrective lens for shortsightedness. Take a page of the newspaper and bring it regularly towards your eyes. You need to note the distance where the letters get blurry.	What is your distance ?



Have you ever taken the pill?	Never - than 5 years from 5 to 10 years + than 10 years
Do you have or have you had an IUD?	Simple with hormones
Do you use or have you used another type of hormonal birth control (pill? implant?)	Never -than 1 year from 1 to 5 years + than 5 years
If you have periods, what are they like?	Not heavy very heavy
Are your periods?	not painful painful the day before painful the day before and briefly the first day if it lasts more than three days
If your periods are regular: indicate the duration of your cycle:
If your periods are irregular:	too long too short irregular
Are you tired after your period ?	Never Sometimes Often Always
On a scale of 1 to 10, what was/is your sexual appetite: at age 20:
Now :
Do you have cellulite?	no a little a lot

After filling in this questionnaire, reading and having accepted the interpretation conditions, having confirmed above and expressed my payment conditions, HALO will send to me:

1. Interpret my questionnaire: in other words the check-up of my health to the present, related to my age and the forecasted quality of my longevity.

2. Establish a program of advise concerning my lifestyle, my nutrition, my personal treatment related to changing my lifestyle, eating habits or nutritional and/or hormone supplements concerning my health and my ageing.

· When it receives your on-line questionnaire, HALO agrees to ask you if necessary, by e-mail, for further details that its experts may require or additional information if necessary. At this point, if your answers allow it, its expert will send you a short interpretation of your test.

· After receipt of the payment, the HALO expert agrees to send you the complete interpretation of the questionnaire within ten working days, along with your optimisation program for a duration of six months as well as any means necessary for following it and monitor your program and its effects.

Afterwards a follow-up to see if you reached your goals is possible. Please contact us, after your first program is established on the website www.maxlongevity.com for more information on the conditions and details.

CONDITIONS FOR INTERPRETING THE QUESTIONNAIRE AND ESTABLISHING A HALO SUPPLEMENTATION CHECKUP

I have been informed:

· That this confidential and personal questionnaire is for the sole purpose of a PERSONAL NUTRITIONAL and/or HORMONAL OPTIMIZATION PROPOSAL, within the framework of optimizing my health and longevity.

· No interpretation or supplement proposal shall be made unless all the conditions described below are accepted in their entirety.

· This questionnaire and its answers may only regard the person who confirms his/her identity below, and which HALO shall maintain confidential.

· Neither this questionnaire nor the answers I provide shall constitute a medical consultation, nor be considered as a substitute for such.

· Consequently, no medical diagnosis shall be made.

· The decision, acquisition and consumption of the proposed supplements is under my sole and total responsibility and in no case shall HALO be held liable, which has not delivered any prescription but only approaches and suggestions.

· To this end, none of the proposed approaches (surveys, analyses, tests, supplement recommendations) can be considered as any type of coverage by a Health Insurance for any expenditures related to the personal nutritional and/or hormonal optimisation proposition.

· Only e-mails will be considered by HALO: no post, fax or attached files will be considered unless expressly requested by HALO.

· HALO shall not be required to reveal the identity of the experts used for this on-line consultation, moreover other types of "anti-aging consultations" are possible, based on your possibilities, those of the experts and where you live.

· HALO is not connected to any Company which manufactures, sells or distributes nutritional or hormone supplements, and to this end it may advise you on the choice of supplement form or brand.

· Due to the above reasons, HALO shall not be held liable for any side effects or unexpected effects of the supplements used.

I hereby confirm:

· that I am the author of the questionnaire answers,

· that I am over 18,

· that I do not believe I have any contraindications against following the advise or taking such or such proposed supplements nor that there is an interaction with such or such medicine which I take or I have taken in the past. If necessary I shall ask my general practitioner to ensure that all of the above conditions are met.

I hereby request that HALO archive in its memories all the transmitted information to be used to follow-up on my results:
yes no
However, I can ask HALO to destroy this data at any time.

Please write the following in the field below and do not forget to confirm your identity:
" I hereby confirm that I am over 18, am the author of the answers above, have read and accept the conditions for interpreting the questionnaire and establishing a checkup of the HALO supplements, and I agree as stated above to make sure I can follow this advise. " Date and confirm your identity.

Methods for paying Halo

I will pay by credit card (the amount of 160 euro)

I will pay by SWIFT International wire transfer the amount of 160 euro to :

BARCGB 22 Code Bank 204735

Account “Health An Longevity Optimization” (HALO)

Account type 63542411

I will be responsible for any charges for these various payments.

Attach proof and identification below (wire transfer number, name on the wire transfer, name and address of the issuing bank : :

Do you have vaginal dryness or painful intercourse?	no yes I don't know
Do you have chest pains, swelling of the chest or mastitis?	Never Sometimes Often
Have you had a mammogram in the last two years?	No mammogram normal mammogram chest to be monitored
Do you have or have you had "micro calcifications" on a mammogram?	no yes I don't know
Do you have or have you had "cysts" on a mammogram?	no yes I don't know
Have you ever had fibromas or a fibromatous uterus on a uterus sonogram (pelvic sonogram)?	no yes I don't know
Do you have or have you had ovarian cysts on an uterus sonogram (pelvic sonogram)?	Never In adolescence Often
Are you in menopause (absence of periods)?	yes no not quite less than one year from 1 to 3 years more than three years
Do you have hot flashes?	no yes I had them
Do you take or have you taken hormone replacements (HRT)?	Never - than 1 year from 1 to 5 years + than 5 years
If you take hormone replacements please specify the form: Estrogen:	by patch in gel in tablets
Progesterone:	I don't take it Intra-vaginally in tablets in gel in lotion (natural progesterone)
If you do not take replacement hormones, please specify:	I refused to take them. I did not tolerate them they were not prescribed for me I was forbidden from using them due to contraindication
If you did not tolerate them, please specify:	Weight gain headache depression other intolerance
Do you take or have you taken plant estrogens (yams, wild yams, soy, other plants) for hormonal purposes or for hot flashes?	never yes I took them but stopped Sometimes
Do you take or have you taken DHEA?	never yes regularly I took it but stopped Sometimes
If you take it, you take:	Less than 25 mg/day from 25 to 50 mg/day + than 50 mg/day
If you have stopped taking certain hormone supplements, please specify which and why:
If you are over 55 have you taken a bone density test (bone densitometer)?	No yes, it was normal I have abnormal bone loss
During your lifetime have you ever had a cancerous or precancerous disease, like dysplasia of the throat ?	no yes I don't know
If you have had in the past six months a recent dosage of hormones: estradiol, progesterone, SDHEA, PREGNENOLONE, and you want to let us know what the doses are, specifying if you still have periods, on which day of the cycle (compared to the first day of your period) they were taken:



On a scale of 1 to 10, what was/is your sexual appetite: at age 20:
Now :
On a scale of 1 to 10, what was/is your sexual capacity: at age 20:
Now :
Have you recently had a decrease in sexual appetite ?	no yes weak Major
Do you have erection problems ?	never sometimes often almost always
Do you have night time or morning erections?	often rarely not at all
Have you had or could you have had a scrotum injury (even old)? (sports, accident etc.)	yes no I don't know
Have you had or could you have had a genital or urinary tract infection, even if a long time ago?	yes no I don't know
Do you have painful scrotum or testicles, even minimal?	yes no
On which side?	on the right on the left
Are you muscular?	no a little Very
If you exercise do you develop muscles easily?	yes very easily no
Has your muscular strength decreased recently ?	yes no
Do you have difficulty urinating during the day?	never rarely often
Do you get up to urinate during the night?	never 1 time every once in awhile 1 time per night + 2 times per night
If you have had a rectal touch in the last six months?	Normal prostate Prostate enlarged and regular Prostate enlarged and irregular
If you have had a prostate sonogram in the last six months?	Normal prostate Prostate enlarged and regular Prostate enlarged and irregular
If you have had a PSA (prostate specific antigen) test in the last six months:	less than 1 between 1 and 3 greater than 3
If you have had several of these tests in the last five years they were?	Basically identical fluctuating increasing decreasing
Have you ever had a cancerous or precancerous disease in your lifetime?	yes no I don't know
Could your father, brothers or uncles have had prostate cancer?	yes no I don't know