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Clinical Longevity Assessment

Welcome to Your Clinical Longevity Assessment

This short assessment evaluates your sleep quality, stress recovery, energy stability, and overall vitality.

Please answer honestly for accurate results.

Name

Email Address

Rate each question following the scale:

1️⃣ Never / Almost Never 2️⃣ Rarely 3️⃣ Sometimes 4️⃣ Often 5️⃣ Always /Almost Always

Sleep

Q1. During the past month, how often have you had trouble sleeping because you could not fall asleep within 30 minutes?

Q2. During the past month, how often have you felt excessively sleepy or fatigued during the day?

Nutrition

Q3. Do you eat fish or seafood at least 3 times per week?

Q4. Do you consume vegetables more than once per day?

Physical Activity

Q5. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, aerobics, or fast cycling?

Q6. During the last 7 days, on how many days did you walk for at least 20 minutes at a time?

Q7. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Q8. In the last month, how often have you felt confident about your ability to handle your personal problems?

Connection

Q9. I feel close to other people.

Q10. I feel disconnected from the world around me.

Purpose

Q11. I have a sense of direction and purpose in life.

Q12. I live life one day at a time without clear goals or plans.

Cognition

Q13. Do you have difficulty concentrating or focusing on tasks?

Q14. Do you forget why you went from one part of the house to another?

Risk Avoidance

Q15. How often do you have a drink containing alcohol?

Q16. Do you currently smoke any tobacco products, such as cigarettes, cigars, or pipes?

Burnout

Q17. I feel emotionally drained from my work.

Q18. I feel very energetic.

Age

Location

This assessment is designed for educational and wellness coaching purposes only. It is not a

diagnostic tool and does not replace medical or psychological evaluation. All questions are derived or adapted from validated research instruments, including PSQI, MEDAS, IPAQ, PSS-10, SCS-R, Ryff, CFQ, AUDIT-C, and MBI. The goal is to promote awareness and positive behavior change aligned with evidence-based longevity principles.