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Health Assessment - Noosa Longevity Health or the clinic
test
General information
Your Goals and Priorities
General Health (Medical Doctor)
Physical Function and Strength (Physiotherapist)
Cognitive and Mental Health (Neuropsychologist)
Nutrition and Lifestyle (Dietician)
Health Screening (For Clinic Use)
General information
What city and country is currently your main residence?
Select a Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Argentina
Armenia
Australia
Austria
Azerbaijan
Bangladesh
Belgium
Brazil
Canada
China
Colombia
Cuba
Denmark
Egypt
Finland
France
Germany
Greece
Hong Kong
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Japan
Jordan
Kazakhstan
Kenya
South Korea
Kuwait
Lebanon
Malaysia
Mexico
Morocco
Netherlands
New Zealand
Nigeria
Norway
Pakistan
Philippines
Poland
Portugal
Qatar
Romania
Russia
Saudi Arabia
Singapore
South Africa
Spain
Sweden
Switzerland
Syria
Thailand
Turkey
Ukraine
United Arab Emirates
United Kingdom
United States
Vietnam
Yemen
Zimbabwe
Biological sex at birth
Male
Female
Family History
Family history of cardiovascular disease
No
Yes
Please Specify
Age and cause of death of parents
Female Patients Section
Use of Menopausal Hormone Therapy (MHT)
No
Yes
Please Specify
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Your Goals and Priorities
What is your goal for visiting Noosa Longevity Health ? What do you hope to achieve?
Is there something specific you feel Noosa Longevity Health should focus on in your health?
Do you have any specific health concerns?
No
Yes
Please Specify
What three things are most important for you to be able to do at age 80?
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General Health (Medical Doctor)
Age (18 - 120)
Height
Weight
Do you have any diagnosed chronic conditions?
None
Yes
Please Specify
Current medications or supplements
None
Yes
Please Specify
Have you had surgeries or hospitalizations?
None
Yes
Please Describe, including dates
Rate your overall health (1 = poor, 10 = excellent)
1
2
3
4
5
6
7
8
9
10
Family history of longevity
No relatives lived past 80
Relatives lived past 80
Other major diseases (please specify)
Please Specify
Do you have family history of cancer , diabetes or dementia?
Yes
No
Please Specify
Average hours of sleep per night
<4
4-5
5-6
6-7
7-8
8-9
>9
Do you feel rested?
Yes
No
Do you snore loudly or experience sleep disturbances?
No
Yes
Please Specify
Smoking or recreational drug use
Never
Past (quit when?)
Current (frequency)
Please Specify amount & frequency
Alcohol consumption
None
<1 drink/week
1-3 drinks/week
4-7 drinks/week
>7 drinks/week
Do you have any allergies or drug allergies?
No
Yes
Please Specify
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Physical Function and Strength (Physiotherapist)
Frequency of physical activity
None
1-2 times/week
3-4 times/week
5+ times/week
Type
Ease with daily tasks
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Decline in strength, balance, or mobility in past 5 years
No
Yes
Please Describe
Joint pain, stiffness, or muscle weakness
None
Yes
Please Specify location and severity
History of falls or balance issues
No
Yes
Please Specify when and what happened
Strength training routine
No
Yes
Please Specify frequency and type
Current fitness level (1 = poor, 10 = excellent)
1
2
3
4
5
6
7
8
9
10
Can you walk briskly for 30 minutes without discomfort?
Yes
No
Please Explain
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Cognitive and Mental Health (Neuropsychologist)
Mood and Emotional Wellbeing: In the past month, have you experienced any of the following?
Feeling down, depressed, or hopeless
Little interest or pleasure in doing things
Trouble concentrating
Increased irritability or mood swings
Trouble sleeping or sleeping too much
None of the above
If any selected, would you like to discuss this further with your doctor?
Yes
No
Cognitive Engagement: Do you regularly engage in mentally stimulating activities?
Yes
No
Occasionally
Please Specify list the types of activities you do
Changes in memory, focus, or decision-making
No
Yes
Please Describe
Stress level (1 = low, 10 = high)
1
2
3
4
5
6
7
8
9
10
Anxiety, depression, or mood swings
None
Yes
Please Specify frequency and severity
Diagnosed neurological or mental health conditions
No
Yes
Please Specify
Social engagement
Rarely/Never
1-2 times/week
3-4 times/week
Daily
History of head injuries or concussions
No
Yes
Please Specify when and severity
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Nutrition and Lifestyle (Dietician)
Typical daily diet
Dietary pattern
None
Mediterranean
Keto
Vegetarian
Vegan
Other
Please Specify
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Health Screening (For Clinic Use)
Prostate Cancer Screening (PSA Test): Have you had a PSA blood test for prostate cancer?
Yes, within the last 2 years
Yes, more than 2 years ago
No
Not applicable
Abnormal results or follow-up needed?
Yes
No
Breast Cancer Screening (Mammogram): Have you had a mammogram for breast cancer screening?
Yes, within the last 2 years
Yes, more than 2 years ago
No
Not applicable
Abnormal results or follow-up needed?
Yes
No
Cervical Cancer Screening (Pap smear or HPV test): Have you had a cervical screening test?
Yes, within the last 5 years
Yes, more than 5 years ago
No
Not applicable
Abnormal results or follow-up needed?
Yes
No
Bowel Cancer Screening (Fecal Occult Blood Test – FOBT): Have you completed a fecal occult blood test?
Yes, within the last 2 years
Yes, more than 2 years ago
No
Not applicable
Abnormal results or follow-up needed?
Yes
No
Bone Density Screening (DEXA Scan): Have you had a bone density scan (DEXA)?
Yes, within the last 5 years
Yes, more than 5 years ago
No
Not applicable
Abnormal results or follow-up needed?
Yes
No
Skin Cancer Screening (Full-body Skin Examination): Have you had a full-body skin check?
Yes, within the last 1 year
Yes, more than 1 year ago
No
Not applicable
Abnormal results or follow-up needed?
Yes
No
Other Screening Tests: Have you had any other screening tests (e.g., abdominal ultrasound, eye exam, or other imaging/lab tests)?
Yes
No
Abnormal results or follow-up needed?
Yes
No
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