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* 1. Pick a user name (real name or pseudonym)

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* 2. email

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* 3. DOB

Date / Time

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* 4. What is your sex?

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* 5. Height in feet and inches? (For example, 5 foot 4 would be 5’4”)

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* 6. Weight in pounds

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* 7. Lifetime maximum weight

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* 8. Mother still living?

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* 9. Mother's age at death, or present age

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* 10. Father still living?

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* 11. Father's age at death (or present age)

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* 12. How many of your grandparents lived past age 90?

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* 13. Present work status

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* 14. Income level

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* 15. Shift work?

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* 16. Is your life stressful?

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* 17. Are you caring for an ailing relative or friend?

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* 18. Tobacco use?

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* 19. Marijuana use?

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* 20. Alcohol use?

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* 21. Have you ever used narcotics?

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* 22. Have you ever used hallucinogens or psychedelic drugs?

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* 23. How many hours sleep do you usually get?

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* 24. Do you snore or have apnea?

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* 25. How often do you have insomnia?

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* 26. Which best describes your dreaming?

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* 27. Do you take anything at bedtime to help you sleep?

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* 28. Who do you live with?

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* 29. Do you engage regularly in any of these community activities?

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* 30. Is this kind of service a big part of your life?

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* 31. Social life - check all that apply

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* 32. Relationship status - check all that apply

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* 33. Sitting meditation?

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* 34. Psychotherapy

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* 35. Do you think of yourself as an artist, writer, or musician?

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* 36. Have you donated blood in the last year?

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* 37. Do you take saunas or steam baths?

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* 38. How many hours do you spend in a typical week watching TV or Youtube or Netflix or going out for a movie?

0 10 20
i We adjusted the number you entered based on the slider’s scale.

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* 39. How's your mobility?

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* 40. Do you get headaches?

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* 41. Mood question - check all that apply

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* 42. Your diet profile

  Big part of my diet Regular part of my diet Eat sometimes Eat occasionally Never eat
Fruits
Root vegetables (including potatoes)
Green vegetables
Legumes (beans, peas)
Nuts (including peanuts)
Bread
Pasta
Rice, bulghur, quinoa, other grains
Dairy
Seafood
Poultry
Red meat
Eggs
Dairy
Sweets and desserts
Artificial sweeteners
Mushrooms, other fungi
Chocolate

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* 43. Characterize your diet (check all that apply)

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* 44. Coffee, tea, and soft drinks

  Rarely or never Less than 1 cup per day 1 to 2 cups per day 3 or more cups per day
Coffee
Decaf
Tea
Decaf Tea
Caffeinated soft drinks
Sweet soft drinks
Artificially sweetened soft drinks

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* 45. If you have had a recent reading of A1C please record it here

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* 46. On a typical day, what time do you finish your last meal before bed?

Date / Time

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* 47. On a typical day, what time do you breakfast in the morning?

Date / Time

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* 48. Do you practice intermittent fasting?

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* 49. Do you fast for multiple days?

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* 50. Have you tried the Longo 5-day Fasting-Mimicking Diet?

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* 51. What time do you usually go to bed at night?

Date / Time

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* 52. What time do you usually wake in the morning?

Date / Time