Lifestyle Medicine Assessment — Dr. Elizaveta Kutis

Please complete this questionnaire so we can evaluate the lifestyle factors influencing your well-being, longevity, and overall health potential.

Your Details

Email (required to submit form) Date of Birth (for personalized wellness mapping)

Your daily nutrition pattern Fruit & vegetable intake per day

Weekly moderate activity Strength training (2× weekly?)

Hours of sleep Your perceived sleep quality

Symptom	0	1	2	3	4	5
Fatigue
Brain fog / concentration issues
Memory difficulties

Your perceived stress level

Emotional Symptom	0	1	2	3	4	5
Anxiety
Low mood

Quality of your social environment Do you feel loneliness or lack of meaningful connection?

Smoking Alcohol use

Symptom	0	1	2	3	4	5
Weight gain / difficulty losing weight
Hair loss
Decreased libido

Rate how strongly you experience the following patterns (0 = not at all, 5 = very strong)

Alignment with your personal direction What gives you a sense of meaning?

Blood Work Supplements Genetics HRV Bioscan DEXA Scan Wellness Consultation Injections

This questionnaire collects non-medical lifestyle information only.