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?