Longevity Assessment
Complete each section together. Scores update in real time. Click Save & Download to create a file with all responses baked in — open it anytime to update and track improvement.
Fast forward one year: What is the single most important metric that will tell you this program was a success?
If you were to design an optimal program to achieve your goals, what would it look like? What kind of support and communication do you need from me to be most successful?
What have been your biggest barriers or roadblocks to maintaining healthy habits in the past?
Depression Screening (PHQ-2)
Over the past 2 weeks, how often have you been bothered by:
Little interest or pleasure in doing things
Select... Not at all Several days More than half the days Nearly every day
Feeling down, depressed, or hopeless
Select... Not at all Several days More than half the days Nearly every day
⚠ PHQ-9 Extended Depression Screening
Trouble falling or staying asleep, or sleeping too much Select... Not at all Several days More than half the days Nearly every day
Feeling tired or having little energy Select... Not at all Several days More than half the days Nearly every day
Poor appetite or overeating Select... Not at all Several days More than half the days Nearly every day
Feeling bad about yourself — or that you are a failure Select... Not at all Several days More than half the days Nearly every day
Trouble concentrating on things Select... Not at all Several days More than half the days Nearly every day
Moving or speaking so slowly others noticed, or being fidgety / restless Select... Not at all Several days More than half the days Nearly every day
Thoughts that you would be better off dead or of hurting yourself Select... Not at all Several days More than half the days Nearly every day
Anxiety Screening (GAD-2)
Over the past 2 weeks, how often have you been bothered by:
Feeling nervous, anxious, or on edge
Select... Not at all Several days More than half the days Nearly every day
Not being able to stop or control worrying
Select... Not at all Several days More than half the days Nearly every day
⚠ GAD-7 Extended Anxiety Screening
Worrying too much about different things Select... Not at all Several days More than half the days Nearly every day
Trouble relaxing Select... Not at all Several days More than half the days Nearly every day
Being so restless it's hard to sit still Select... Not at all Several days More than half the days Nearly every day
Becoming easily annoyed or irritable Select... Not at all Several days More than half the days Nearly every day
Feeling afraid as if something awful might happen Select... Not at all Several days More than half the days Nearly every day
Social Connection
Do you live alone?
Select... No Yes
Contact with friends or family at least once a week?
In person, phone, or video
Select... Yes No
Do you often feel lonely?
Select... No Yes
Marital / relationship status
Select... Married or in a committed partnership Never married Divorced Separated Widowed
Sense of Purpose
"I have a sense of direction and purpose in my life."
Select... Strongly Disagree Disagree Neutral Agree Strongly Agree
Tobacco use status
Select... Never used tobacco Former — quit 20+ years ago Former — quit 15–20 years ago Former — quit 10–15 years ago Former — quit 5–10 years ago Former — quit less than 5 years ago Current — less than 1 cigarette/day Current — 1–14 cigarettes/day Current — 15–24 cigarettes/day Current — 25–34 cigarettes/day Current — 35+ cigarettes/day
Do you monitor the Air Quality Index (AQI) in your area?
Select...
Yes
No
Do you take steps to reduce your exposure when AQI is elevated?
e.g. wearing an N95 outdoors, running a HEPA air filter indoors
Select...
Yes
No
At what AQI level do you take action?
Select...
25 or above
50 or above
100 or above
150 or above
200 or above
Have you used any of these medications at least once in the past year?
Alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), diazepam (Valium), temazepam, oxazepam
Select... No Yes
Have you used any of these medications at least once in the past year?
Zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata)
Select... No Yes
PPI (proton pump inhibitor) in the past year?
Omeprazole, Nexium, Prevacid, Protonix, etc.
Select... No Yes — with Barrett's esophagus or gastric ulcer history Yes — without Barrett's or ulcer history
Sleep Apnea Screening (STOP)
Snore loudly (loud enough to hear through closed doors)?
Select... No Yes
Often feel tired, fatigued, or sleepy during the day?
Select... No Yes
Has anyone observed you stop breathing during sleep?
Select... No Yes Don't know
📋
Meal Diary
Record what you typically eat on a weekday and weekend day to reference while answering the nutrition questions below.
📅
Typical Weekday
☀️ Breakfast
🥤 Drinks at breakfast
🌤 Morning snack
🌞 Lunch
🥤 Drinks at lunch
🌥 Afternoon snack
🌙 Dinner
🥤 Drinks at dinner
🌛 After dinner
🏖
Typical Weekend Day
☀️ Breakfast
🥤 Drinks at breakfast
🌤 Morning snack
🌞 Lunch
🥤 Drinks at lunch
🌥 Afternoon snack
🌙 Dinner
🥤 Drinks at dinner
🌛 After dinner
Beneficial Foods
Fruit per day servings per day
Legumes (beans, lentils, chickpeas) servings per week
Nuts or seeds times per week (0 = never)
Extra virgin olive oil daily tsp per day (0 = none)
Coffee per day cups per day
Tea (green or black) per day cups per day
Foods to Limit
Sodium exposure Select... Cook most meals at home, minimal salt, rarely eat out Cook often but eat some packaged or restaurant food Eat out or packaged foods several times per week Mostly restaurant or ready-to-eat foods
Deep-fried foods servings per week
Eggs per week eggs per week
Whole milk per week cups per week
Do you take glucosamine daily?
Select... No Yes
Coronary Artery Calcium (CAC) Score
Recommended age 40+. Score of 0 is strongly protective; ≥100 indicates significant plaque burden.
Select... Done — enter score below Not done / age <40
Select score... 0 1–99 100 or higher
Ages 30 to 44: PREVENT Calculator
Ages 45 or Older: MESA Risk Calculator
