Birth of date: Month / Day / Year


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1. Do you often feel tired? Yes No

2. Do you feel happy most of the time? Yes No

3. Do you often go through mood swings? Yes No

4. Do you get angry easily? Yes No

5. Are you depressed often? Yes No

6. Do you feel anxious or stressed out? Yes No

7. Do you feel you work to hard? Yes No

8. Do you look forward to retirement? Yes No

9. Do you keep in touch with friends? Yes No

10. Do you maintain interest in sex? Yes No

11. Is your sex life decling? Yes No

12. Do you have trouble falling or staying asleep? Yes No

13. Do you feel rested after you sleep? Yes No

14. Do you find your self forgetting things? Yes No

15. Do you find it hard to think clearly? Yes No

16. Do you use memory aids? Yes No

17. Do you have problems concentrating? Yes No

18. Are you in poor physical shape? Yes No

19. Are you more than 20% above your ideal weight? Yes No

20. Is it very difficult to you to lose weight? Yes No

21. Have you developed a spare tire or love handles? Yes No

22. Does your musculature look youthful? Yes No

23. Do you feel your overall health is good? Yes No

24. Do you often get cold or feel sick? Yes No

25. Do you commonly feel aches or pains? Yes No

26. Is your blood cholesterol over 200? Yes No

27. Is your blood cholesterol over 240? Yes No

28. Men - is your HDL less then 45? Yes No

29. Women - is your HDL less then 55? Yes No

30. Is your blood pressure normal? Yes No

31. Has your vision noticeably deteriorated? Yes No

32. Do you have frequent urination? Yes No

33. Do you have digestive problems? Yes No

34. Does the skin on your face, neck, upper arms, and abdomen appear to hang? Yes No

35. Do you think you look older than your age mates? Yes No

36. Do you need hair cut less frequently? Yes No

37. Does it seem to take a long time for cuts and bruises to heal and for wounds to close? Yes No

38. Is it getting harder to exercise? Yes No

39. Do you seem to have less strength for gripping or lifting? Yes No

40. Is your endurance less? Yes No

41. Is your breathing more labored when you exercise hard? Yes No

42. Do you ding the longer you live the better you feel about life? Yes No

43. Are you 45 to 54? Yes No

44. Are you 55 to 64? Yes No

45. Are you 65 or above? Yes No