Longevity Test. ¡ FREE !

Dr. Lázaro Vidal Campillo (MD.)

Age of birth:

PART A

IDENTITY
Gender	Male Female

Heredity
Any grandparent lived to be over 80 (limit 4)	Yes No
Average age all four grandparents lived to	60 -70 71 - 80 Over 80

Family History
Either parent had stroke or heart attack before age 50	No Yes

PART B

PART C

PART D

PREVENTIVE AND THERAPEUTIC MEASURES
Comprehensive physical exams and blood tests	Every 3 or 4 years before 50. Every 1 or 2 years over 50 Never or no regular physical exams and blood tests

MEN
Genital self-exam every 3 months	Yes No
Rectal or prostate exam (yearly after age 30)	Yes No or under 30

Longevity Test. ¡ FREE !

PART A

IDENTITY

Gender

Heredity

Any grandparent lived to be over 80 (limit 4)

Average age all four grandparents lived to

Family History

Either parent had stroke or heart attack before age 50

A family member (grandparent, parent, sibling) who prior to age 65, has had any of the following:

Hipertension

Cáncer

Heart disease

Stroke

Diabetes

Other genetic diseases

PART B

ENVIROMENTS

Family income

Education

Temperament (Others would describe you:)

Where you live

Total commuting time to and from work

Major medical/ trauma center

Occupation(Choose one)

Occupation (Choose one)

Regularly in direct contact with pollutants, toxic waste,or carry a firearm to work

¿Probability of career advancement?

PART C

HEALTH STATUS

Present overall physical health:

Blood Pressure (if measured within the last year)

Cholesterol Total:

HDL Cholesterol

Do you or close family member have diabetes?

Insurance Coverage

Tobacco (1 pipe= 2 cigarettes, 1 cigar = 3 cigarettes)

Pack-years smoked ( # de pack/day,* times number of years smoked)

Alcohol daily consumption (1 beer or 1 glass of wine = 1,25 Oz)

Exercise (20 min. or more moderate aerobic exercise)

How many flights of stairs (about 12 steps) do you climb each day?.

Work requires regular physical exertion

After taking a brisk walk, do you feel any of those symptoms:racing hearts, irregular heartbeat or chest pain?

Need more than two pillows to sleep comfortably ( If yes, see your doctor before begining any exercise program.))

Weight

Weight

Determine your waist (W) and hip (H) ratio in inches.( Divide your W measure by your H measure)

Nutrition

Eat a well-balanced diet

Regularly eat meals at consistent times

Snack or eat meals late at night

Eat a balanced breakfast

Eat fish or poultry as primary protein source

Eat at least 5 servings of green leafy vegetables/week

Eat at least 5 servings of fresh fruit or juice/day

Try to avoid fats

Fifty percent of meal consist of fried take-out foods, prepackaged or precooked foods

Eat some food every day that is high in fiber (wholw grain bread,fresh fruits and vegetables)

Take a daily multivitamin or mineral supplement wich includes at least the followings: Vitamin A/beta-carotene, vitamin E, vitamin B-complex, zinc,selenium, vitamin C, Omega 3-6.

Take calcium supplement (Women)

Do you get colds or other infection more than once every eight weeks?

Does is take a long time to get over a bad infection? (For example do your colds typically last longer than two weeks?)

Do you need antibiotics three times/ years or more?

Are your lymph nodes often enlarged?

Regularly use sunscreen and avoid excesive sun

Suscribe to health-related periodicals

Actively involved in a life-extension prevention or comprehensive wellness program

PART D

ACCIDENT CONTROL

Always wear a seat belt as driver and passengers

Never drink and drive or ride with a driver who has been drinking

Arrest or ticket for driving under the influence of alcohol in the past 5 years

Speeding ticket or accident in the past year

Miles driven per year (last year)

Primary car

Fight or attack you were involved in or witness to, in the past 3 years.

Smoke alarms in home.

PREVENTIVE AND THERAPEUTIC MEASURES

Comprehensive physical exams and blood tests

WOMEN