Senior Access Onboarding

1. Basic Information 0/6

Date: *

First Name: *

Last Name: *

Birthdate: *

Primary Care Physician: *

Physicians/Healthcare Providers:

2. Current Medications & Supplements 0/14

Please list all prescription medications, over the counter medications and supplements you currently take:

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3. Physical Biomarkers 0/3

What is your current height? *

What is your current weight? *

Current Blood Pressure (If unknown, please enter "Unknown") *

4. Allergies 0/7

Are you allergic to any of the following?

Do you have any other food allergies?

Do you have any drug allergies?

If yes, please list drug or food allergies below:

5. Medical History 0/1

Please list any surgeries and pregnancies with corresponding years:

6. Women's Health 0/4

OB/GYN:

Women: Date of Last Menstrual Period:

Women: Have you had a hysterectomy?

Yes No

If yes, do you still have your ovaries?

Yes No

7. Medical Conditions 0/9

Have you ever had any of the following?

Have you ever had any form of cancer?

Yes No

Have you ever been told you have heart blockage?

Yes No

Have you ever had a heart attack?

Yes No

Have you ever had a stroke or mini stroke (TIA)?

Yes No

Have you ever had a blood clot?

Yes No

Have you ever been told you have a clotting disorder?

Yes No

Are you on SSRIs?

Yes No

Are you on MAO Inhibitors?

Yes No

Are you on MAO Activators?

Yes No

Please check all medical conditions that apply:

Abnormal Bleeding Prostate Issues Epilepsy/Seizure Hepatitis Rheumatic Fever Gout Emphysema/COPD Diabetes Liver Disease (Including Fatty Liver Disease) Kidney Disease Urinary Problems Kidney Stones Ulcer Arthritis Anemia Osteoporosis/Osteopoenia Chronic Anxiety High Blood Pressure Low Blood Pressure Asthma Peripheral Vascular Disease Depression Sexual Dysfunction Seasonal Allergies Polycystic Ovarian Syndrome (PCOS) Alzheimer's High Cholesterol Migraines Addison's Disease Thyroid Disease Frequent Urine Infections Autoimmune Disease (Rheumatoid Arthritis, Fibromyalgia, Hashimotos, etc.) Sleep Apnea Vitamin D3 Deficiency Metabolic Syndrome Malabsoprtion Syndrome (Celiac Disease, Lactose Intolerance, etc.) Hyperglycemia

Please list any additional medical problems you have had with diagnosis year:

8. Family History 0/16

This is important in determining your overall medical history. Please include medical problems of parents and siblings.

Family History - Alzheimer's

Yes No

Family History - Osteoporosis/Osteopoenia

Yes No

Family History - Parkinson's

Yes No

Family History - Depression

Yes No

Family History - Cancer

Yes No

Family History - Diabetes

Yes No

Family History - Heart Disease

Yes No

Family History - High Blood Pressure

Yes No

Family History - Heart Attack

Yes No

Family History - Stroke/TIA

Yes No

Family History - High Cholesterol

Yes No

Family History - Anxiety

Yes No

Family History - Thyroid Disease

Yes No

Family History - Obesity

Yes No

Family History - Autoimmune Disease

Yes No

Family History - Blood Clots or Clotting Disorder

Yes No

9. Health Symptoms 0/1

Do you have any of the following symptoms? (check all that apply)

Mental/Cognitive

Irritable Moody Increased Anxiety Inability to Shut Down Mind Stressed/Overwhelmed Decreased Motivation Foggy Brain Decreased Work Efficiency Decreased Memory

Sleep

Trouble Falling Asleep Trouble Staying Asleep Night Sweats

Physical

Hair Changes/Thinning Increased Abdominal Fat Muscle Cramps Food Cravings PMS Symptoms Poor Exercise Recovery Joint Pain Fatigue Weight Gain Headaches Hot Flashes Bloating After Meals Constipated Loose Stools Decreased Physical Stamina Loss of Muscle Mass Decreased Metabolism Unable to Build Muscle Easy Bruising Vaginal Dryness General Feeling of Weakness Skin Prone to Wrinkling Multiple Food Sensitivities

Sexual

Decreased Sex Drive

10. Sexual Health 0/18

Sexual Function Assessment (check all that apply):

Little Interest in Sex Few Thoughts Related to Sex Decreased Start/ Rejecting of Sex Little Pleasure During Sex Most of the Time Decreased Sexual Interest Even When Exposed to Erotic Stimuli Little Genital Sensations During Sex Most of the Time Trouble Getting or Maintaining Erections

Rate the following (1=Bad, 3=Good, 5=Great, or N/A):

11. Social History 0/8

Tobacco use?

Yes No

Are you exposed to second hand smoke?

Yes No

Alcohol use 3x a week or more?

Yes No

Do you smoke marijuana?

Yes No

Are you exposed to chemicals at your work?

Yes No

Do you exercise at least 3 times a week?

Yes No

Do you have a good support system for a wellness program?

Yes No

What diets have you tried? List all that apply and any results:

12. Stress Analysis 0/3

Rate your stress from 1 (Low) to 10 (High):

What are your sources of stress?

How do you cope with or relieve your stress?

13. Early Detection/Preventative Health 0/16

If you have had any of the following tests, please indicate approximate date of testing and the result:

Cholesterol/Lipid Blood Test

Cardiac Stress Test

Chest X-Ray

Colonoscopy

Pelvic Ultrasound

Mammogram

Papsmear

PSA

14. Skin Symptoms 0/1

Do you have any of the following symptoms? (check all that apply)

Acne Loss of Elasticity in Neck Cellulite Redness (Rosacea) Dark Circles Sagging or Drooping Skin Dry Skin or Scalp Smile Lines or Pronounced Jowls Dull Skin Stretch Marks Excessive Peach Fuzz Submental Fat (Double Chin) Excessive Sweating Sun Spots Fine Lines Texturized Skin Hollow Under Eyes Thin Lips Hooded Eyes or Hooded Eye Lids Volume Loss in Face Due to Age Hyperpigmentation Wrinkles Large Pores