Your nutritional check-up

The "mini questionnaire" includes around a hundred questions and parameters used for a faster and simpler evaluation, both for those filling out the questionnaire and the expert who evaluates it. Its cost (see the end of the questionnaire) is thus lower than the complete questionnaire which as 190 questions. On the other hand, it does not focus much on environmental and dietary problems and much less on biological parameters. We have maintained the essential clinical and biological parameters required for optimising ageing. However, they cannot be used to precisely evaluate a biological age (for a definition of this: read Doctor Jaeger's text "Biological Age" in our document centre, a concept developed to fight ageing. » 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 centimetres)?
How tall were you at 18?
What is your waist measurement?



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
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 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 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:



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
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



Do you regularly take medicine? If yes, please specify the medicine and the dosage and number taken per day for each one:
Your fasting glucose level (sugar in the blood in grams/liter) Is it:	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 from 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
Does anyone suffer from high blood pressure in your family?	Yes No I don't know
Does anyone suffer from cancer in your family?	Yes No I don't know
Please provide more details on your medical history (yours or family), if you know them:
Has anyone in your family suffered from dementia (Alzheimer's disease, or similar diseases)?	Yes No
Does anyone suffer from Parkinson's disease in your family?	Yes No
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
Do you have or have you had ringing, whistling or noises in your ears?	Yes No
Do your legs hurt or feel heavy?	Never Sometimes Often Recently
Do you have fillings?	One from 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 or have you had sinusitis?	Never Sometimes Often
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



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
How many children do you have?
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 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
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 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
Are you muscular?	no a little Very
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 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

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 100 euro)

I will pay by SWIFT International wire transfer the amount of 100 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 :