PRE-CONSULTATION HEALTH & LONGEVITY QUESTIONNAIRE

Home address

Emergency contact name and number

Are there any other symptoms we should know about now such as chest pain, blackouts, unexplained bleeding, marked weight loss, new neurological symptoms, or severe breathlessness?

Please list any medical conditions you have now or have had in the past

Have you ever had any significant childhood illness, recurrent infections, or other major medical events including hospital visits & stays?

Have you ever had COVID-19 with prolonged symptoms or any other post-viral issues?

Have you had any past operations or procedures? If yes, please list them with approximate dates

Have you ever had cosmetic procedures, body contouring, or regenerative procedures? If yes, which ones?

Have you ever had any mental health diagnosis?

Please list all prescription medicines and supplements you currently take. Include dose and frequency if known.

Are you currently using any hormones, peptides, injectables, performance enhancing drugs, or other compounded treatments?

Have you ever stopped a medication or supplement because of side effects or because it didn't help?

Are there any treatments you're keen to avoid?

Please tell us which relative was affected and at what age, if known

How much alcohol do you drink in a typical week?

Do you use / have you used any recreational drugs, cannabis, nicotine pouches, or other substances?

How would you describe your current stress levels and mood?

Do you have good support at home and work?

How many hours do you usually sleep each night, and how good is your sleep?

Do you have any sleep problems such as difficulty getting to sleep, staying asleep, snoring, waking unrefreshed, or daytime sleepiness?

How are your energy levels during the day, and how well do you recover from exercise, stress, travel, or poor sleep?

Do you have any injuries, pain, or physical limitations that affect training or mobility?

Have you noticed reduced strength, reduced stamina, or poorer recovery over time?

How would you describe your diet, including any particular dietary approach you follow?

Do you have any digestive symptoms such as bloating, reflux, abdominal pain, altered bowel habit, rectal bleeding or other food related symptoms?

Have you had any significant or unexpected weight change or change in appetite over the past 12 months?

Do you struggle with cravings, overeating, under eating, or poor satiety?

Have you ever followed a medically supervised nutrition or weight loss programme?

Do you have any concerns around libido, sexual function, menstrual or menopausal health, fertility, or hormone related symptoms?

For women: are you pregnant, trying to conceive, breastfeeding, peri-menopausal, post-menopausal, or using contraception or HRT?

For men: do you have any concerns around sexual function, fertility, testicular health, or low testosterone symptoms?

Have you had any previous hormonal or fertility treatment?

Have you had any blood tests in the last 3 months? YesNo

If yes, could you send us copies or let us know when these were done and what the main findings were?

Please upload any other recent results or reports you'd like us to review before your consultation. You can upload multiple files.

Have you tried any interventions for longevity, prevention, optimisation, body composition, hormones, or recovery?

Did anything cause side effects, disappointment, or concern?

HbA1c, fasting glucose, or continuous glucose data, if known

Cholesterol or other CVD risk marker results, if known

How proactive would you like your care to be?
Conservative and minimalBalanced and pragmaticHighly proactive within sensible medical limits

Are there any specific treatments, therapies, or medications you were hoping to discuss?

Is there anything else you'd like us to know before your consultation?