The Health Status and Longevity Questionaire.

Of course no one can tell you exactly how long you will live, but over the years physicians have discovered several factors that significantly affect life span. Think of this test as more of an educational experience than an empirical, scientific analysis. Most of the questions are about changeable behavior, so a few simple modifications in lifestyle can alter the score -- and possibly add a few years to your future.

The test below is a modified version of an extensive questionnaire developed by Ronald Klatz and Robert Goldman. To take their more complete version of the longevity test, check out their new book, "Stopping the Clock," or visit the World Health Network website.

  • What is your gender?

    Male
    Female

  • Has either of your parents had a stroke or heart attack before age 50?

    Yes
    No

  • Has either parent suffered from any of the following before age 65:

    Hypertension
    Cancer
    Heart disease
    Stroke
    Diabetes
    Other genetic disorders

  • What is your annual family income?

    0-$9,000
    $10,000-$18,000
    $19,000-$30,000
    $31,000-$75,000
    $76,000-$150,000
    Greater than $150,000

    Health Status:

  • How would you describe your present overall health?

    Excellent--almost never ill.
    Good--sick 10 days or less each year.
    Fair--sick 11-20 days each year.
    Poor--sick 21 days or more each year.

  • What is your blood pressure?

    Normal -- below 140/90 mmHg
    Borderline -- between 140/90 and 160/95
    High -- above 160/95
    Don't know.

  • What is your cholesterol count?

    Low -- under 200
    Moderate -- 200-240
    High --over 240
    Don't know.

  • How much tobacco do you use?

    Never smoked
    Quit smoking
    Smoke up to one pack a day
    Smoke one to two packs a day
    Over two packs a day

  • What is your daily consumption of alcohol? (1 beer or 1 glass of wine = 1.25 oz.)

    No alcohol
    1.25 oz./day or less
    1.25-2.5 oz./day
    More than 2.5 oz./day

  • How often do you do exercise aerobically for 20 minutes or more?

    5 or more times a week
    4 times a week
    3 times a week
    2 times a week
    1 time a week
    No regular aerobic exercise

  • Does your work requires regular physical exertion?

    Yes
    No

  • What is your weight?

    Ideal weight
    5-10 pounds over ideal weight.
    11-20 pounds over ideal weight
    21-30 pounds over ideal weight
    More than 30 pounds over ideal weight
    5-10 pounds under ideal weight
    More than 11 lbs. under ideal

  • Do you eat a well-balanced diet?

    Yes
    No

  • Do you regularly eat meals at a consistent time?

    Yes
    No

  • Do you snack or eat meals late at night?

    Yes
    No

  • Do you eat fish or poultry as primary protein source?

    Yes
    No

  • Do you eat at least 5 servings of vegetables a week?

    Yes
    No

  • Do you try to avoid fats?

    Yes
    No

  • Do at least half of all your meals consist of take-out foods, prepackaged or precooked foods?

    Yes
    No

  • Do you eat some food every day that is high in fiber?

    Yes
    No

  • Do you take a daily multivitamin or mineral supplement?

    Yes
    No

  • Are you married or in long-term committed relationship?

    Yes
    No

  • Do you have a pet?

    Yes
    No

  • How many hours do you sleep a night?

    8-10
    5-8
    less than 5

  • Do you have a regular work routine?

    Yes
    No

    • SF-12 HEALTH QUESTIONNAIRE

    INSTRUCTIONS: This questionnaire asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities.

    To mark your answer to a question, click on an empty circle, eg. , and it will become marked, eg..

    Please answer every question by marking one choice. If you are unsure about how to answer, please give the best answer you can.

    Use the scrolling arrow at the bottom-right corner of this page to proceed to the next question.

    #1. In general, would you say your health is:

    Excellent
    Very Good
    Good
    Fair
    Poor

    The following items are about activities you might do during a typical day. Does YOUR HEALTH NOW LIMIT YOU in these activities? If so, how much?
    #2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

    #3. Climbing several flights of stairs

    Yes, Limited
    A Lot
    Yes, Limited
    A Little
    No, Not Limited
    At All

    During the PAST 4 WEEKS, have you had any of the following problems with your work or other regular daily activities AS A RESULT OF YOUR PHYSICAL HEALTH?
    #4. Accomplished less than you would like

    #5. Were limited in the kind of work or other activities

    Yes
    No

    During the PAST 4 WEEKS, have you had any of the following problems with your work or other regular daily activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)?
    #6. Accomplished less than you would like

    #7. Didn't do work or other activities as carefully as usual

    Yes
    No

    #8. During the PAST 4 WEEKS, how much did PAIN interfere with your normal work (including both work outside the home and housework)?

    Not at all
    A little bit
    Moderately
    Quite a bit
    Extremely

    These questions are about how you feel and how things have been with you DURING THE PAST 4 WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the PAST 4 WEEKS -
    #9. Have you felt calm and peaceful?

    #10. Did you have a lot of energy?

    #11.Have you felt downhearted and blue?

    All
    of the Time
    Most
    of the Time
    A Good Bit
    of the Time
    Some
    of the Time
    A Little
    of the Time
    None
    of the Time

    #12. During the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)?

    All of the time
    Most of the time
    Some of the time
    A little of the time
    None of the time

    MOST IMPORTANT: When you are done, enter your SUBJECT ID NUMBER by pressing on and typing in the box below. Finally, press on the REPORT MY ANSWERS button.

    Enter your SUBJECT ID NUMBER in this box:
    I have answered all 12 questions
    and entered my ID number. I wish to: