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)

Nutrition

Your daily nutrition pattern Fruit & vegetable intake per day

Physical Activity

Weekly moderate activity Strength training (2× weekly?)

Sleep

Hours of sleep Your perceived sleep quality

Stress, Emotional Load & Social Environment

Your perceived stress level Primary sources of stress Do you experience chronic emotional tension? Quality of your social environment Do you feel loneliness or lack of meaningful connection? Who provides emotional support in your life?

Habits

Smoking Alcohol use

Purpose & Meaning

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

Your Goals

Readiness to Change

How ready are you to make lifestyle changes? (0–10)

Diagnostics & Wellness Services

Please indicate which services you are interested in exploring as part of your personalized wellness plan.

Blood Work (comprehensive biomarkers) Supplements (personalized formulation) Genetic Analysis (deep dive into genes) HRV Bioscan (autonomic nervous system assessment) DEXA Scan (body composition & bone health) Wellness Consultation (personalized plan) Injections (NAD+, B12, peptides)

This questionnaire collects non-medical lifestyle information to support personalized wellness mapping only. No protected health information (PHI) is collected.