Longevity Optimization Activation Form
Share your health, lifestyle, and testing details (including any available lab uploads) for data collection only.
Client ID
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Biological sex at birth
Female
Male
Intersex
Prefer not to say
Family cardiovascular, cancer, and neurodegenerative risk categories
Cardiovascular
Cancer
Neurodegenerative
Unknown
Sleep duration (hours per night)
Resting heart rate
HRV if tracked
Recent falls
No
Yes
Unsure
Exertional symptoms
Unintended weight loss
No
Yes
Unsure
Medication or supplement side effects
Allergies or sensitivities
Provider-support needs
Primary healthspan goals
Family history and major risk factors
Current diagnoses (medical conditions)
Current medications, supplements, peptides, hormones, or GLP-1
Weight (lbs)
Waist circumference (inches)
Body composition (if known, e.g., % body fat or muscle)
Blood pressure (if known)
How would you rate your sleep quality?
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How would you rate your daily energy levels?
Very low
1
2
3
4
5
6
7
8
9
Very high
10
1 is Very low, 10 is Very high
How would you rate your cognition (memory, focus, clarity)?
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How would you rate your stress level?
Very low
1
2
3
4
5
6
7
8
9
Very high
10
1 is Very low, 10 is Very high
How would you rate your digestion?
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How would you rate your inflammation or pain?
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
How would you rate your strength?
Very weak
1
2
3
4
5
6
7
8
9
Very strong
10
1 is Very weak, 10 is Very strong
How would you rate your balance?
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How would you rate your mobility?
Very limited
1
2
3
4
5
6
7
8
9
Very mobile
10
1 is Very limited, 10 is Very mobile
How would you rate your cardiovascular fitness?
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Average daily steps (if known)
Weekly exercise (type, frequency, duration)
How would you describe your nutrition overall?
Average daily protein intake (grams, if known)
Average daily servings of plant foods (fruits, vegetables, legumes, etc.)
How often do you consume alcohol?
Please Select
Never
Occasionally
Weekly
Daily
Prefer not to say
Do you currently use tobacco or nicotine products?
No
Yes
Former user
Prefer not to say
Wearable device data (if available; e.g., Oura, Apple Watch, Fitbit)
Are you willing to undergo additional testing if recommended?
Yes
No
Unsure
How ready do you feel to begin a wellness optimization program?
Not ready
1
2
3
4
5
6
7
8
9
Very ready
10
1 is Not ready, 10 is Very ready
Do you have any symptoms or safety concerns that should be addressed before starting?
Submit
Should be Empty: