Aeturnia — Health 3.0 Intake

Personal & Identity

Basic demographics and contact details

First Name

Last Name

Date of Birth

Biological Sex

Ethnicity

Contact

Mobile

Street Address

Physician Notes — Demographics

Longevity Vision

Define your "why" and your physical legacy in the marginal decade

The Centenarian Decathlon

List three physical tasks you must still be able to perform in your 90s. Be specific — these become your training targets.

Examples: carry 20 lb groceries up stairs · get up off the floor unaided · hike 5 miles · pick up a grandchild · play 18 holes

01

02

03

Primary Motivation

Primary longevity goal

Readiness to Change

On a scale of 1–10, how willing are you to make aggressive changes to your diet, exercise, or pharmacology to extend your healthspan?

5

1 — Curious only5 — Moderate10 — All in

Physician Notes — Longevity Vision

Medical & Surgical History

Current conditions, past surgeries, and hospitalizations

Current Conditions *

Other conditions not listed

Surgical & Hospitalization History *

None — no past surgeries or hospitalizations

Past surgeries, procedures, or hospitalizations

Physician Notes — Medical History

Family History

High-resolution cardiovascular, neurodegenerative, and longevity data

Early-Onset Cardiovascular Risk

Did any first-degree relative have a heart attack or stroke before age 55 (men) or 65 (women)?

If yes — specify relative, event, and age

Conditions in First-Degree Relatives *

Longevity Data

Father's age or age at death

Father's cause of death

Paternal grandfather — age at death

Mother's age or age at death

Mother's cause of death

Maternal grandmother — age at death

Physician Notes — Family History

Medications & Supplements

All current prescriptions, OTC drugs, and your longevity stack

Prescription Medications *

Type to search — names auto-complete from the NIH RxNorm drug database. Add dose and frequency for each.

None — I take no prescription medications

Allergies *

Drug allergies and adverse reactions — names auto-complete from RxNorm.

None — no known drug allergies

Supplements & Longevity Stack *

Vitamins, minerals, and longevity-targeted supplements — name auto-completes from a curated list. Type freely if your supplement isn't listed.

None — I take no supplements

Physician Notes — Medications & Supplements

Sleep Architecture & Recovery

Sleep quality, efficiency metrics, and wearable recovery data

Core Metrics

Average nightly sleep duration

Sleep quality (self-rated)

Typical bedtime

Typical wake time

Precision Sleep Efficiency

Sleep latency — how long to fall asleep?

Night wakings — how many times per night?

Wearable sleep data available?

Average HRV from wearable (if known)

Sleep Issues *

Sleep Aids *

None — I don't use sleep aids

Sleep aids or interventions currently using

Physician Notes — Sleep

Exercise & Metabolic Health

The four pillars of longevity training and your metabolic baseline

The 4 Pillars of Training

Zone 2 — Aerobic Base

Steady-state cardio where you can still hold a full conversation. The foundation of metabolic health and mitochondrial density.

Minutes per week

Primary modality

VO2 Max — Peak Output

High-intensity interval work that pushes your cardiovascular ceiling. VO2 max is one of the strongest predictors of longevity.

Max-effort interval sessions per week

Estimated VO2 max (wearable or formal test)

Strength Training

Resistance training preserves muscle mass, bone density, and insulin sensitivity — all critical for healthspan in the later decades.

Days per week

Primary focus

Stability — Balance, Mobility & Foot Health

The most overlooked pillar. Stability training prevents the falls and joint failures that end independence in the later decades.

Nutrition

Primary dietary approach

Daily protein target (if tracking)

Current weight

Height

Food sensitivities, allergies, or restrictions

Metabolic Baseline — Existing Biomarkers

Enter recent results if you have them — these are often missed in standard primary care

ApoB (most recent)

Lp(a) (most recent)

Fasting Insulin

Body fat % (DEXA if known)

Most recent HbA1c

VO2 max (formal test, if done)

Physician Notes — Exercise & Metabolic

Stress & Cognitive Function

Mental sharpness, psychological wellbeing, and stress management

Cognitive Self-Assessment

Rate each on a scale of 1 (poor) to 10 (excellent)

Focus & Concentration

7

1 — Poor10 — Excellent

Memory & Recall

7

1 — Poor10 — Excellent

Mental Energy / Brain Fog

7

FoggySharp

Describe any specific cognitive concerns

Stress & Mental Health

Overall stress level (past 3 months)

Primary stress source

Mental Health History *

Stress Management & Recovery Practices *

Social History

Tobacco use

Alcohol use

Occupation

Work stress level

Physician Notes — Stress & Cognitive

Tech & Wearables

Devices you use and your data-sharing preferences

Devices Currently Used *

Primary device (if multiple)

Data Sharing

Are you willing to share your wearable dashboard for real-time monitoring by your Aeturnia physician?

Anything else you'd like us to know?

Physician Notes — Tech & Final Assessment