Intake · Longevistic

1. Basics

Demographics the score needs, plus history that changes the consult.

First name

Last name

Preferred name

Date of birth

Biological sex (score uses this)

Race (score uses this)

Height

Weight

Enter a valid email (name@domain.com).

Mobile

Enter a 10-digit US number.

State

City

ZIP code

Enter your 5-digit ZIP code.

Where you live. We use it to find CAC, DEXA and VO₂ max test sites near you.

Primary goal this cycle

First full baseline Lower heart and artery risk Improve ApoB / cholesterol Improve blood sugar Reduce visceral fat Build muscle and strength Raise fitness / VO₂ max Sleep better Energy and recovery Hormones / menopause

2. Medical history

Diagnoses, medications, symptoms, family history, and substances. Family history, smoking, and alcohol enter the score.

Known conditions

None Hypertension Prediabetes Diabetes Coronary artery disease (CAD) / stent / CABG Atrial fibrillation Chronic kidney disease (CKD) Thyroid Sleep apnea Osteopenia / osteoporosis Cancer history Other

Specify other condition

Current medications

Tick everything you take now, including by injection. Some results are read differently on these medicines.

None Statin (atorvastatin, rosuvastatin, simvastatin…) PCSK9 inhibitor Ezetimibe Other cholesterol or triglyceride medicine (fibrate, bempedoic acid, niacin, prescription fish oil) Aspirin Blood pressure medicine Metformin GLP-1 medicine (semaglutide, tirzepatide, liraglutide) SGLT2 inhibitor (empagliflozin, dapagliflozin) Other diabetes medicine (insulin, sulfonylurea, DPP-4) Thyroid hormone (levothyroxine, liothyronine, desiccated thyroid) Iron (tablets or infusions) Estrogen Progesterone Testosterone Other

Other medicines (name and dose if you know it)

Symptoms in the last 3 months

Tick any that apply. They help us read thyroid, iron and heart results and plan training safely.

None of these Unusual tiredness or fatigue Shortness of breath with light activity Chest pain or pressure on exertion Palpitations (racing or skipped heartbeats) Heat intolerance (feeling too hot when others don’t) Cold intolerance (feeling too cold when others don’t)

Chest pain right now, or chest pain at rest: call 911. Don’t wait for your plan.

Family history of premature CAD

1st-degree: father/brother <55, mother/sister <65

None Exactly 1 relative 2 or more

Tobacco / nicotine

Vape, pouch, cigar, chew, and hookah count.

Never Former (≥1 yr quit) Quit <1 yr Current

Alcohol, drinks / week

0 1–3 4–6 7 or more

Binge drinking

≥4 drinks women / ≥5 men in 2 hours, last 30 days.

No Yes

Other substance use

Flag anything used in the last 12 months. This does not add score points.

None Cannabis Cocaine Methamphetamine Non-prescribed opioids Non-prescribed benzodiazepines Non-prescribed stimulants Other

Specify other substance

Allergies and reactions

Medications, foods, or supplements that caused a reaction.

None known Medication Food Supplement Other

Specify other

List allergens and reactions, separated by commas

Pregnancy and menopause

Not applicable Premenopause Perimenopause Postmenopause Pregnant Trying to conceive

Date of last menses (if known)

3. Diet

LNQ-8 items are yes/no. Typical week, not a perfect week.

A. Protein

Daily protein ≥1.2 g/kg (0.55 g/lb), ≥5 days/week Two meals ≥30 g protein, ≥5 days/week

B. Food quality

≥5 servings/day vegetables and fruit (≥3 vegetable + ≥2 fruit). Juice is not fruit. ≥2 servings/day legumes, intact grains, or nuts/seeds Main added fat is unsaturated (olive, avocado, nuts, seeds) Processed meat ≤1 serving/week Sugary drinks (including juice) and sweets ≤1 day/week

C. Override

Substantial ultra-processed food on ≥3 days/week

Usual pattern

None / no pattern Mediterranean High protein Pescatarian Vegetarian Vegan Low-carb Keto Other

Specify other pattern

Meals away from home

0–1 / week 2–4 / week 5+ / week

Intermittent fasting

Days / week

0 1 2 3 4 5 6 7

Hours / day

12–13 14–15 16–17 18–19 20+

Or other pattern

Other pattern

Describe the pattern

4. Exercise

Steps enter the score. Session counts are consult context, not scored.

Wearable

None Whoop Apple Oura Garmin Fitbit Other

Which wearable

Average daily steps

Enter your average daily steps. Use an estimate if you do not have an exact number.

Average daily steps

Resistance sessions / week

0 1 2 ≥3

Zone 2 / easy cardio sessions / week

0 1 2 ≥3

Hard sessions (Zone 4–5 / VO₂) / week

0 1 2 ≥3

Training load

A typical week over the last month. Count all planned exercise, not daily walking.

Hours of training per week Main types of training

No regular training Endurance (running, cycling, swimming, rowing) Strength / resistance Intervals / HIIT Team or racket sport Yoga, Pilates or mobility Other

Morning seated resting HR

Not sleep HR. After 5 minutes seated.

Injury currently limiting training

No Yes

5. Recovery

Sleep duration and consistency enter the score. Prefer 4-week average.

Sleep duration, typical night

Hours

Minutes

Sleep midpoint variation

Minutes between earliest and latest mid-sleep, 4-week preferred. Whoop % only if minutes unknown.

≤30 min 31–45 min 46–75 min 76–120 min >120 min

Whoop / wearable consistency % if no minutes

Screens off before bed

≥60 min 30 min In bed with phone

Caffeine after 2 pm

Rarely Most days

Shift work or frequent jet lag

No Yes

Perceived stress most weeks

Low Moderate High

Sauna / heat

None 1 / week 2–3 / week ≥4 / week

Red light / near-infrared

None 1 / week 2–3 / week ≥4 / week

Hyperbaric oxygen (HBOT)

None Past course Current protocol

6. Supplements

What you take most days. No doses here.

Supplements

None Multivitamin Vitamin D Vitamin K2 Omega-3 Magnesium Zinc Iron B12 Folate Creatine Protein powder Collagen CoQ10 Fiber / psyllium Plant sterols Bergamot Berberine Red yeast rice Probiotic Curcumin NAC Glycine Electrolytes Ashwagandha Melatonin Other

Specify other supplements

7. Skincare

Not scored. Useful for protocol and product recommendations.

Sunscreen most days

Yes No

Retinoid

Tretinoin, retinal, or retinol.

None Prescription OTC

Skin issues

None Acne Rosacea Eczema Sun damage Other

Specify other skin issue

In-office procedures last 12 months

None Laser IPL Botulinum toxin Filler Other

Specify other procedure

9. Labs

Use values from the last 6 months. Next: consent, then submit.

None within 6 months

Enter results

Type the values below. Prefer draws within 6 months.

Uploading a lab report PDF or photo opens soon. For now, please type the values below.

Genova NutrEval this cycle

Default first-cycle nutrient panel. OmegaQuant only if NutrEval is not done.

Not done Order this cycle Already done

NutrEval date

Biological aging clock

Supporting — always

Supporting — if already done

8. Imaging and function

Imaging and office measures from the last 6 months. If you can’t or don’t want to do a test, you can opt out below it.

None within 6 months

Blood pressure

Prefer out-of-office. One date for the pair. mmHg.

Systolic

Diastolic

Date

Don’t have this yet

10. Consent

Please read and tick both boxes, then select Submit. There’s nothing to sign: we record your consent with your account.