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Anti Aging Meta Analysis, MetaAnalysis
 

Meta Analysis

If you would like to participate in the eternity-medicine.com Anti-Aging program, please fill out the Meta-Analysis below and mail to:

EM
5060 Meadowood Mall Cir.
Reno, NV 89502

Please include a check for $350 made out to EM. Your Meta-Analysis will be scored by our medical doctors and returned to you with your biomarker profile. In addition, you will also receive a customized wellness and longevity program tailored to fit your individual needs.

We will email you a lab slip on receipt of your check, which you can take to any Quest Diagnostics. There are over 1,000 draw sites nationwide. Click here to find the Quest Lab closest to you. You should fast for 12 hours (you may drink water only). The cost of the lab work is included in the above fee.

Note: Before beginning the Meta-Analysis section G; Biomarkers Of Aging see Appendix A. Caution.

Part I
Section A: Lifestyle Questionnaire
Section B: Nutrition Questionnaire
Section C: Exercise Questionnaire
Section D: Stress Questionnaire
Section E: Hormonal Health Questionnaire
Section F: Physical Examination
Section G: Biomarkers of Aging

Part II
Section A: Mood Questionnaire

Part III
* Section A: Sexual Questionnaire
Section B: Ecology Questionnaire
Section C: World-View Wellbeing Questionnaire

Part IV
Alternative Medicine Questionnaires (Optional)
Section A: Traditional Chinese Medicine
Section B: Ayurvedic Medicine
Section C: Chiropractic Medicine
Section D: Anthroposophical Medicine
Section E: Naturopathic Medicine
Section F: Homeopathic Medicine

* Part III Section A is optional.

PART I

Name: __________________________ Date: __________________


SECTION A:

You can begin by answering questions about your lifestyle and health

1. What is your height? ___________

2. What is your weight? ___________

3. Describe your blood pressure:

a. Low
b. Medium
c. High
d. Unknown

4. What is your blood pressure?

a. Systolic number (the top number e.g. 120/80) ___
b. Diastolic number (the bottom number) ____
c. Unknown

5. Describe your total cholesterol:

a. Low
b. Medium
c. High
d. Unknown

6. What is your total cholesterol?

a. ____________
b. Unknown

7. Estimate the size of your body frame?

a. Small
b. Medium
c. Large

8. How healthy are you?

0 1 2 3 4 5 6 7
Very Unhealthy Very Healthy

9. How often did you consult a physician in the past year?

a. o d. 3 g. 9 j. 9 m. 16 - 20
b. 1 e. 4 h. 7 k. 10 n. 21 - 25
c. 2 f. 5 i. 8 l. 11 - 15 o. more than 25
times

10. How often did you consult a chiropractor in the past year?

a. o d. 3 g. 6 j. 9 m. 16 - 20 p. 31 - 40
b. 1 e. 4 h. 7 k. 10 n. 21 - 25 q. 41 - 50
c. 2 f. 5 i. 8 l. 11 - 15 o. 26 - 30 r. more than 50
times

11. Are you currently seeing a psychologist, psychiatrist or some other mental health worker?

a. Yes
b. No



12. Did you consult with any other health care provider in the past year (e.g.
massage therapist, physical therapist, acupuncturist)?

a. No
b. Yes. If yes, indicate the type(s) of health care providers you consulted with __________________

13. Indicate below any health problems you currently have (circle as many as apply):

a. lung disease (e.g. asthma, emphysema, bronchitis etc.)
b. cancer
c. gastro-intestinal disorder (e.g. ulcers, colitis, gall bladder attacks, frequent diarrhea etc.)
d. chronic pain
e. genito-urinary disorder (e.g. kidney problems, prostate, problems with genitals etc.)
f. endocrine disorder (e.g. diabetes, thyroid, etc.)
g. heart disease (e.g. history of heart attack, angina, irregular heart beat, high blood pressure)
h. neurological disorder (e.g. Parkinson's disease, epilepsy, migraine headaches, etc.)
i. blood disorder (e.g. leukemia, anemia, etc.)
j. rheumatoid disorder (e.g. arthritis, etc.)
k. eye disorder (e.g. cateracts, glaucoma, etc.)
l. skin disorder (psoriasis, eczema, etc.)
m. sexual impotence
n. ears, nose and throat problems (e.g. inflamed throat, ear aches, etc.)
o. musculosketal (e.g. painful, stiff muscles, frequent tension headaches, etc.)
p. other ____________
q. none


14. Have you received any of the following medical procedures in the past 3 years (circle as many as apply)

a. Upper GI
b. Lower GI
c. Ultrasound
d. MRI
e. Cat Scan
f. X-Ray
g. EEG (brain wave recording)
h. EKG (heart monitoring)
i. Mammogram
j. Other (write in) ________________
k. None

15. What medications are you currently taking? If you do know the name of the medication, indicate type
of medication it is (e.g. heart, high blood pressure, pain pills, etc.)

1. ___________________
2. ___________________
3. ___________________
4. ___________________
5. ___________________
6. ___________________

______ Check here if you are taking no medications

16. How many minor or major surgeries have you had in the past 3 years?

a. 0 d. 3
b. 1 e. 4
c. 2 f. 5 or more
17. How many times have you visited the emergency room in the past year?

a. 0 d. 3 g. 8 - 10
b. 1 e. 4 h. over 10 times
c. 2 f. 5 - 7


18. How many times have you been hospitalized in the past 3 years?

a. 0 d. 3
b. 1 e. 4
c. 2 f. 5 or more

19. What is the general health of your mother?

a. deceased (indicate the cause of death and the age at which your mother died) _____________
b. poor
c. fair
d. good
e. excellent
f. unknown

20. What is the general health of your father?

a. deceased (indicate the cause of death and the age at which your father died) _____________
b. poor
c. fair
d. good
e. excellent
f. unknown

21. Indicate if there is a history of the following health problems in your family and relatives (circle as may apply):

a. heart disease
b. cancer
c. diabetes
d. high blood pressure
e. stroke
f. obesity
g. ulcer
h. high cholesterol
i. other (write in) ________________
j. none


22. How physically active are you?

0 1 2 3 4 5 6 7
Not at all active Very active

23. Do you follow a regular fitness routine?

0 1 2 3 4 5 6 7
Not at all Most Definitely

24. Do you get an adequate amount of sleep each night?

0 1 2 3 4 5 6 7
Not at all Very Much

25. How many hours of sleep do you average each night?

a. 3 hours or less d. 6 g. 9 or more
b. 4 e. 7
c. 5 f. 8

26. How many meals on the average do you eat each day?

a. 1 d. 4 g. 7
b. 2 e. 5 h. 8
c. 3 f. 6 i. 9

27. Do you eat between meals?

0 1 2 3 4 5 6 7
Never Very often

28. Do you skip breakfast?

0 1 2 3 4 5 6 7
Never Very often

29. Do you eat meals that are nutritionally sound?

0 1 2 3 4 5 6 7
Not at all Most Definitely
30. Indicate how many cups of coffee you drink per day.

a. 0 d. 4 - 5
b. 1 e. 6 - 7
c. 2 - 3 f. 8 or more

31. Indicate how many cups of regular (not herbal) tea you drink per day:
a. 0 d. 4 - 5
b. 1 e. 6 - 7
c. 2 - 3 f. 8 or more

32. Indicate how many soft drinks that contain caffeine you drink per day (e.g. regular Coke, Pepsi,
Diet Coke, Tab etc.)

a. 0 d. 4 - 5
b. 1 e. 6 - 7
c. 2 - 3 f. 8 or more

33. How many cigarettes do you smoke daily?

a. none d. 21 - 30
b. 1 - 10 e. 31 - 40
c. 11 - 20 f. over 2 packs daily

34. How long have you smoked cigarettes?

a. never smoked d. 11 - 15 years
b. 1 - 5 years e. 16 - 20 years
c. 6 - 10 years f. over 20 years

35. If you quit smoking, how long has it been since you quit?

a. less than 1 year d. 7 - 10 years
b. 1 - 3 years e. over 10 years
c. 4 - 6 years


36. If you quit smoking, how long did you smoke cigarettes?

a. never smoked d. 11 - 15 years
b. 1 - 5 years e. 16 - 20 years
c. 6 - 10 years f. over 20 years

37. How many cigars did you smoke daily?

a. None d. 3
b. 1 e. 4
c. 2 f. over 4 daily

38. How many pipes of tobacco do you smoke daily?

a. None d. 3
b. 1 e. 4
c. 2 f. over 4 daily

39. How often do you use smokeless tobacco daily?

a. None d. 3 g. 6
b. 1 e. 4 h. 7
c. 2 f. 5 i. Over 8 times daily

40. On the average, how many alcoholic beverages (e.g. wine, beer
and hard liquor) do you consume in a week?

a. None d. 11 - 15 g. 26 - 30
b. 1 - 5 e. 16 - 20 h. over 30
c. 6 - 10 f. 21 - 25

41. How stressful has your life been in the past 12 months?

0 1 2 3 4 5 6 7
Not Stressful at all Extremely Stressful

42. How many of the following supplements do you take?
a. multivitamins d. herbs
b. minerals e. others _________
c. anti-oxidants f. none


SECTION B: NUTRITION QUESTIONNAIRE

Please check yes or no for each statement as it applies to you.

Yes No
1. I enjoy eating and meal time.
2. I know what I eat changes my hormone levels.
3. I have a well-stocked, well-equipped kitchen.
4. I balance carbohydrate, fat and protein at each meal.
5. I read and educate myself about nutrition.
6. I get a balance of many kinds of foods.
7. I know my own personal nutritional needs and know how to meet them.
8. I eat a hearty breakfast, a full lunch, and a lighter supper with two snacks each day.
9. I drink plenty of liquids between meals (6-8 glasses of water).
10. I know and feel the difference between "stomach hunger" and "mouth hunger".
11. I avoid the dangers of trans-fats in foods.
12. I chew my food thoroughly and caringly (avoiding gulping).
13. I enjoy the benefits of omega-3-fats (fish oils).
14. I eat raw fruits and vegetables at least once a day.
15. I steam my vegetables instead of boiling them.
16. I read and understand the labels on packaged foods and choose accordingly.
17. I take vitamin and mineral supplements.
18. I avoid processed and packaged foods.
19. I eat whole (unrefined) grains and whole-grain bread.
20. I use olive oil most of the time for cooking.
21. I try to eat mostly lean meats, turkey and fish.
22. I understand fasting and practice it regularly.
23. I follow the USDA food pyramid.
24. I calorie "conserve" so that I can extend my lifespan.
25. I eat too much/too little when I am bored, depressed, anxious or upset.
26. I eat foods I 'know" are "bad" for me.

Yes No
27. I fear weight gain or loss.
28. I eat very small amounts of carbohydrates.
29. I use wild game as a good protein source.
30. I have several drinks (alcohol) with meals.
31. I feel embarrassed or conspicuous when I eat with others. I wish I looked different.
32. I often try to copy a "Mediterranean" healthy diet.
33. My stools usually float and have a firm consistency.
34. By changing my diet I can prevent most chronic diseases.
35. I use more than one teaspoon of sugar (white or brown) per day.
36. I get cravings for sweets.
37. I go to sleep with a full stomach.
38. My fingernails and hair are strong and healthy.
39. I am groggy on waking.
40. I get fatigued, exhausted, wiped out, crashed out at some times during the day.
Total


SECTION C: EXERCISE QUESTIONNAIRE

1. How would you describe your level of daily activities?

____ Light (e.g. office work)

____ Moderate (e.g. factory work)

____ Heavy (e.g. construction work)

2. Sleeping habits (hours per night) ________

3. What are your health goals?

____ Longevity

____ Weight loss (Decrease weight/decrease fat)

____ Maintain current weight but improve health

____ Gain weight and gain muscle and strength

4. Have you ever been on weight control or weight loss programs
in the past?

_____ Yes _____ No

If yes, how many times? _______

5. Resistance/ Weight Training Experience

o Do you have any previous experience with resistance training?

Y ___ N ____

o If yes, what type of routine (e.g. circuit or split)

o What intensity? ____ Light ____ Moderate ____ Vigorous

o Length of typical work out ________________

o Number of days per week ________________
o Time of daily exercise ________________

o What resistance/weight training do you enjoy?

____________________________________
____________________________________

6. Cardiovascular Training Experience

o Do you perform regular cardiovascular conditioning?

Y ___ N ___

o If yes, what is your typical cardio session?

o Stationery bike ___ Treadmill ___ Elliptical ____

o Rowing ___ Aerobics ___ Cardio Kickboxing ____
o Other ____

o What intensity? ____ Light ____ Moderate ____ Vigorous

o Length of typical cardio routine ________________

o Number of days per week ________________

o Time of daily exercise ________________

o What cardiovascular training do you enjoy?

____________________________________
____________________________________

SECTION D:

STRESS EXHAUSTION CHECK LIST

Check the symptoms of stress exhaustion you've noticed lately in yourself.

PHYSICAL EMOTIONAL SPIRITUAL
Appetite or weight change Anxiety Emptiness
Headaches - tension Frustration Loss of meaning
Fatigue Mood swings Doubt
Insomnia Bad temper No joy
Digestive upsets Crying spells No purpose
Pounding heart Irritability Looking for magic
Accident prone "No one cares" Loss of direction
Teeth grinding Depression Cynicism
Restlessness Worrying Apathy
Increased drug, alcohol, tobacco use Little joy Needing to "prove" self
Total

MENTAL RELATIONAL ENVIRONMENTAL
Forgetfulness Isolation - hiding "Leaky gut" syndrome -- dysbiosis
Low productivity Resentment Poor memory
Negative Attitude Loneliness Chronic fatigue
Confusion Lashing out Any chronic disease
Lethargy Clamming up Liver toxicity
Whirling mind Lowered sex drive Immune depression
No new ideas Nagging Joint pain
Boredom Distrust Skin rash
Spacing out Lack of intimacy Emotional problems
Poor concentration Fewer contacts with friends Allergies --asthma
Total


LIFE CHANGE INDEX

If an event has been true for you in the past year or will occur in the near future, copy the number in
the left column over to the right column. Then total your points.

Event Scale of Impact You
Death of Spouse 100
Divorce 73
Marital Separation 65
Jail Term 63
Death of Close Family member 63
Personal Injury or Illness 53
Marriage 50
Fired at Work 47
Marital Reconciliation 45
Change in Health of Family Member 44
Pregnancy 40
Sex Difficulties 39
Gain of New Family Member 39
Business Readjustment 39
Change in Financial State 38
Death of Close Friend 37
Change to Different Line of Work 36
Change in Number of Arguments with Spouse 35
Mortgage over $10,000 31
Foreclosure of Mortgage or Loan 30
Change in Responsibilities at Work 29
Son or Daughter Leaving Home 29
Trouble with In-Laws 29
Outstanding Personal Achievement 28
Spouse Begins or Stops Work 26
Begin or End School 26
Change in Living Conditions 25
Revision of Personal habits 24
Trouble with Boss 23
Change in Work Hours or Conditions 20
Change in Residence 20
Change in Schools 20
Event Scale of Impact You
Change in Recreation 19
Change in Church Activities 19
Change in Social Activities 18
Mortgage or Loan less than $10,000 17
Change in Sleeping Habits 16
Change in Number of Family Get Togethers 15
Change in Eating Habits 15
Vacation 13
Christmas (if approaching) 12
Minor Violations of the Law 11
Total



SECTION E: HORMONAL HEALTH

ACTH
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I have patches of hair loss. 0 1 2 3 4
2. I have a very pale complexion. 0 1 2 3 4
3. I sunburn easily. 0 1 2 3 4
4. I often have memory loss. 0 1 2 3 4
5. I'm stressed out./I'm facing many difficulties. 0 1 2 3 4
6. My blood pressure has dropped. 0 1 2 3 4
7. My friends tell me I look thinner. 0 1 2 3 4
Total
ALDOSTERONE
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I urinate too many times a day. 0 1 2 3 4
2. I crave salty foods. 0 1 2 3 4
3. My blood pressure is low. 0 1 2 3 4
4. I feel dizzy when I stand up. 0 1 2 3 4
5. I feel much better lying down than standing up. 0 1 2 3 4
Total
CALCITONIN
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I have vertebral fractures (crushes) - compression fractures in my spine. 0 1 2 3 4
2. I've lost height. 0 1 2 3 4
3. My back hurts. 0 1 2 3 4
4. I'm very sensitive to pain. 0 1 2 3 4
5. I have thyroid problems (goiter, thyroid insufficiency, radiation applied to this area). 0 1 2 3 4
Total
CORTISOL
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. My face looks thinner. 0 1 2 3 4
2. My friends call me skinny. 0 1 2 3 4
3. I have eczema, psoriasis, urticaria ("nettle rash"), skin allergies, or other rashes. 0 1 2 3 4
4. My heart beats quickly. 0 1 2 3 4

CORTISOL (cont.)
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
5. My blood pressure is low. 0 1 2 3 4
6. I crave salt or sugar (to the extent of binging). 0 1 2 3 4
7. I have digestive problems. 0 1 2 3 4
8. I have allergies (hay fever, asthma, etc.) 0 1 2 3 4
9. I'm stressed out. 0 1 2 3 4
10. I'm easily confused. 0 1 2 3 4
Total
DHEA
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. My hair is dry. 0 1 2 3 4
2. My skin and eyes are dry. 0 1 2 3 4
3. My muscles are flabby. 0 1 2 3 4
4. My belly is getting fat. 0 1 2 3 4
5. I don't have much hair under my arms. (0=plenty of hair/4=hairless) 0 1 2 3 4
6. I don't have much hair in the pubic area. (0=plenty of hair/4=hairless) 0 1 2 3 4
7. I don't have much fatty tissue in the pubic area (flat "mount of Venus" in women). (0=padded/4 = flat) 0 1 2 3 4
8. My body doesn't have much of a special scent during sexual arousal. 0 1 2 3 4
9. I can't tolerate noise. 0 1 2 3 4
8. My libido is low. 0 1 2 3 4
Total
EPO
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I have a particularly pale complexion. 0 1 2 3 4
2. Prolonged physical effort leaves me breathless. 0 1 2 3 4
3. I'm anemic (diagnosed with a blood test). 0 1 2 3 4
4. "A sense of well-being? What's that?" 0 1 2 3 4

EPO (cont.)
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
5. My blood test shows an increased BUN (blood uric nitrogen) level. 0 1 2 3 4
Total
ESTROGEN
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I am losing hair on top of my head. 0 1 2 3 4
2. I'm getting thin, vertical wrinkles above my lips. 0 1 2 3 4
3. My breasts are droopy. 0 1 2 3 4
4. My face is too hairy. 0 1 2 3 4
5. My eyes are dry and easily irritated. 0 1 2 3 4
6. I have hot flashes. 0 1 2 3 4
7. I feel tired constantly. 0 1 2 3 4
8. I am depressed. 0 1 2 3 4
9. My menstrual flow is light (0=moderate/
1-3=low/4=none). 0 1 2 3 4
10. Women with periods: My cycles are too short (<27 days), or too long (>31 days). 0 1 2 3 4
11. Women without periods:
I do not feel like making love anymore. 0 1 2 3 4
Total
GROWTH HORMONE
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. My hair is thinning. 0 1 2 3 4
2. My cheeks sag. 0 1 2 3 4
3. My gums are receding. 0 1 2 3 4
4. My abdomen is flabby./I've got a "spare tire." 0 1 2 3 4
5. My muscles are slack. 0 1 2 3 4
6. My skin is think and/or dry. 0 1 2 3 4
7. It's hard to recover after physical activity. 0 1 2 3 4
8. I feel exhausted.

GROWTH HORMONE (cont.)
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
9. I don't like the world. I tend to isolate myself. 0 1 2 3 4
10. I feel continuously anxious and worried. 0 1 2 3 4
Total
INSULIN
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I crave sugar and sweets and eat a lot of them. 0 1 2 3 4
2. I'm always thirsty. 0 1 2 3 4
3. I urinate a lot during the day as well as at night. 0 1 2 3 4
4. I have difficulty healing. 0 1 2 3 4
5. My stomach and buttocks are skinny. 0 1 2 3 4
Total
MELATONIN
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I look older than I am. 0 1 2 3 4
2. I have trouble falling asleep at night. 0 1 2 3 4
3. I wake up during the night. 0 1 2 3 4
4. and I can't get back to sleep. 0 1 2 3 4
5. My mind is busy with anxious thoughts while I'm trying to fall asleep. 0 1 2 3 4
6. My feet are too hot at night. 0 1 2 3 4
7. When I get up, I don't feel rested. 0 1 2 3 4
8. I feel like I'm living out of sync with the world, going to bed late and waking up late. 0 1 2 3 4
9. I can't tolerate jet lag. 0 1 2 3 4
10. I smoke, drink, and/or use a beta-blocker or a sleep aid. 0 1 2 3 4
Total

PREGNENOLONE
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I have memory loss. 0 1 2 3 4
2. My joints hurt (fingers, wrists, elbows, feet, ankles, knees). 0 1 2 3 4
3. I'm feeling a bit drained and I have a hard time handling stress. 0 1 2 3 4
4. I don't see colors as brightly as before. 0 1 2 3 4
5. I have lost interest in art; I don't appreciate art as much anymore. 0 1 2 3 4
6. I don't have much hair under my arms or in the pubic area. (0=plenty of hair/4=hairless). 0 1 2 3 4
7. My muscles are flabby. 0 1 2 3 4
8. I have abundant, light-colored urine during the day. 0 1 2 3 4
9. I have low blood pressure. 0 1 2 3 4
10. I crave salty foods. 0 1 2 3 4
Total
PROGESTERONE
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. My breasts are large. 0 1 2 3 4
2. My close friends complain I'm nervous and agitated. 0 1 2 3 4
3. I feel anxious. 0 1 2 3 4
4. I sleep lightly and restlessly. 0 1 2 3 4
Total
The following questions are for women who have not reached menopause and menopausal women who are
taking hormone replacement therapy (estrogen and progesterone).
PROGESTERONE (cont.)
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
5. My breasts are swollen and tender or painful before my period…. 0 1 2 3 4
6. And my lower belly is swollen... 0 1 2 3 4
7. And I'm irritable and aggressive... 0 1 2 3 4
8. And I lose my self-control. 0 1 2 3 4

PROGESTERONE (cont.)
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
9. I have heavy periods… 0 1 2 3 4
10. And they are continuously painful. 0 1 2 3 4
Total
TESTOSTERONE
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. My face has gotten slack and more wrinkled. 0 1 2 3 4
2. I've lost muscle tone. 0 1 2 3 4
3. My belly tends to get fat. 0 1 2 3 4
4. I'm constantly tired. 0 1 2 3 4
5. I feel like making love less often than I used to. 0 1 2 3 4
Total
Signs and Symptoms of Deficiency (MEN ONLY)
TESTOSTERONE (cont.)
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
6. My breasts are getting fatty. 0 1 2 3 4
7. I feel less self-confident and more hesitant. 0 1 2 3 4
8. My sexual performance is poorer than it used to be. 0 1 2 3 4
9. I have hot flashes and sweats. 0 1 2 3 4
10. I tire easily with physical activity. 0 1 2 3 4
Total
THYROID HORMONES
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I'm sensitive to cold. 0 1 2 3 4
2. My hands and feet are always cold. 0 1 2 3 4
3. In the morning my face is puffy and my eyelids are swollen. 0 1 2 3 4
4. I put on weight easily. 0 1 2 3 4
5. I have dry skin. 0 1 2 3 4
6. I have trouble getting up in the morning. 0 1 2 3 4
7. I feel more tired at rest than when I am active. 0 1 2 3 4
8. I am constipated. 0 1 2 3 4
9. My joints are stiff in the morning. 0 1 2 3 4
THYROID HORMONES (cont.)
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
10. I feel like I'm living in slow motion. 0 1 2 3 4
Total
VASOPRESSIN
Signs and Symptoms of Deficiency Never Sometimes Regularly Often Constantly
1. I'm thirsty at night. 0 1 2 3 4
2. I get up at night to urinate. 0 1 2 3 4
3. I bleed a lot when I get hurt. 0 1 2 3 4
4. I'm losing my memory. 0 1 2 3 4
5. I have a hard time thinking straight. 0 1 2 3 4
Total


Note: This section is adopted from "The Hormone Solution" by Thierry Hertoghe, M.D.
SECTION F: PHYSICAL EXAMINATION

Name: ______________________ Date of Exam: ________

Age: ______ Height: ______
Weight: ______

General Appearance

Looks: Younger ( ) Older ( ) than chronological age

Skin: Pink ( ) Pale ( ) Sun Damaged ( ) Dry ( )
Moist ( )

Hair: Full ( ) Thin ( ) Bald ( ) Localized or Total ( )
Grey ( ) Localized or Total ( )
Personal Hygiene: Remarks _____________________________

Vital Signs

Resting BP: _______________ Axillary Temperature (Day 1)__________
Resting HR: _______________ (Day 2)__________
(Day 3)__________

Review of Physical Signs

ENT:

Heart:

Lung:

Abdomen:

Extremities:

Musculoskeletal:

Neurological:

Note: Fill this section out the best you can. You can attach a recent physical from your doctor (optional).
You may wish to attach a recent photo of yourself (optional).

SECTION G: BIOMARKERS OF AGING

Note: You are going to perform a number of biomarkers on yourself.
CAUTION: Before testing your aerobic capacity, read and follow the "caution" in the Appendix A.

Instructions for measuring the biomarkers are found in Appendix B.

Some of the biomarkers are blood tests. Your blood should be drawn once you have fasted for 12 hours. If you have any concerns about fasting, you should contact the lab for advice first. There are over six thousand draw sites in the U.S. alone.

Biomarker Test Results
1. Lifestyle Index Meta analysis
2. Nutritional Index Meta analysis
3. Exercise Index Meta analysis
4. Stress Index Meta analysis
5. Hormonal Index Meta analysis
6. Blood Pressure Monitor
7. Caries Index Inspection
8. Body Mass Index Calculation
9. Waist/Hip Ratio Tape measure
10. Auditory Threshold Watch
11. Aerobic Capacity 2-step test
12. Basal Metabolic Rate Calculation
13. Muscle Strength Dumbells
14. Skin Elasticity Contractile Time
15. Axillary Temperature Thermometer
16. Static Balance Watch
17. Visual Acuity Newspaper
18. Vital Capacity Candle
19. Reaction Time Ruler
20. Body Flexibility Ruler
21. Glucose Blood
22. BUN Blood
23. Cr Blood
24. BUN/Cr Ration Blood
25. Uric acid Blood
26. Phosphorus Blood
Biomarker Test Results
27. Calcium Blood
28. Total Protein Blood
29. Albumin Blood
30. Globulin Blood
31. A/G Ratio Blood
32. Total Bilirubin Blood
33. Direct Bilirubin Blood
34. Indirect Bilirubin Blood
35. Alk Phosphatase Blood
36. ALT (SGPT) Blood
37. AST (SGOT) Blood
38. LDH (total) Blood
39. Sodium Blood
40. Potassium Blood
41. Chloride Blood
42. CO2 Blood
43. Cholesterol Blood
44. Triglyceride Blood
45. HDL Blood
46. VLDL Blood
47. Cholesterol/HDL Ratio Blood
48. Trigylceride/HDL Ration Blood
49. LDL Blood
50. WBC Blood
51. RBC Blood
52. Hb Blood
53. Hct Blood
54. MCV Blood
55. MCH Blood
56. MCHC Blood
57. Red Cell Distribution Blood
58. Platelet Count Blood
59. Mean Platelet Vol Blood
60. Seg. Neutrophils Blood
61. Lymphocytes Blood
62. Monocytes Blood
63. Basophils Blood

Biomarker Test Results
64. PSA Blood
65.
Insulin Blood
66. Testosterone Blood
67. DHEA Blood
68. Estrogen Blood
69. Progesterone Blood
70. Thyroid Blood
71. Cortisol Blood
72. Pregnenalone Blood
73. ACTH Blood
74. EPO Blood
75. Growth Hormone Blood


Note: #66-75 are not routinely included in the lab work.

Part II

SECTION A: Mood Questionnaire

Below are several questions about how you have been feeling over the last few weeks including today.
Please answer each item using the 0-7 scale below. Circle the number that best describes how you are feeling for each item.

Strongly Disagree Strongly Agree

1. Difficulty swallowing 0 1 2 3 4 5 6 7

2. Shortness of breath 0 1 2 3 4 5 6 7
3. Fatigue 0 1 2 3 4 5 6 7

4. Racing heart 0 1 2 3 4 5 6 7

5. Frequently check other 0 1 2 3 4 5 6 7
people's work

6. Feeling tense and keyed up 0 1 2 3 4 5 6 7

7. Crying 0 1 2 3 4 5 6 7

8. Feeling annoyed when criticized 0 1 2 3 4 5 6 7

9. Feel like lashing out 0 1 2 3 4 5 6 7

10. Cold hands 0 1 2 3 4 5 6 7

11. Feelings of anger 0 1 2 3 4 5 6 7

12. Muscle tension or tightness 0 1 2 3 4 5 6 7

13. Quick to feel annoyed 0 1 2 3 4 5 6 7

14. Feelings of sadness or 0 1 2 3 4 5 6 7
depression

15. Feelings of worthlessness 0 1 2 3 4 5 6 7

16. Decreased interest in socializing 0 1 2 3 4 5 6 7
Strongly Disagree Strongly Agree

17. Being discouraged about 0 1 2 3 4 5 6 7
the future

18. Loss of confidence 0 1 2 3 4 5 6 7

19. Feeling shaky 0 1 2 3 4 5 6 7

20. Difficulty motivating yourself 0 1 2 3 4 5 6 7
to do things

21. Dislike waiting in line 0 1 2 3 4 5 6 7

22. Loss of interest in sex 0 1 2 3 4 5 6 7

23. If mistreated you look to pay 0 1 2 3 4 5 6 7
them back

24. Stomach distress 0 1 2 3 4 5 6 7

25. Trouble staying awake 0 1 2 3 4 5 6 7

26. Easily frustrated in traffic 0 1 2 3 4 5 6 7

27. Racing thoughts 0 1 2 3 4 5 6 7

28. Count number of items in 0 1 2 3 4 5 6 7
express checkout ahead of you

29. Overwhelming feelings of dying 0 1 2 3 4 5 6 7

30. Often find yourself muttering 0 1 2 3 4 5 6 7
at news on T.V.


PART III

SECTION A: SEXUAL QUESTIONNAIRE

Please answer the following questions as best as you can. If you need more room to write, continue on
the back. Some questions are gender specific.

Marital status


Single

Divorced

Widowed

Married

Describe your current sexual problems. If your problem is with erections, do you have more trouble:


Getting an erection

Maintaining an erection

Enough foreplay

Orgasm

Intimacy

Painful Intercourse

Other

Do you have a steady sexual partner? Yes ___ No ____

Other (explain) _______________________________________________________________________

____________________________________________________________________________________

When did your current sexual problems begin? _________________________________

Was the onset: Sudden ____ Gradual ____

Other (explain) _______________________________________________________________________

____________________________________________________________________________________

Why do you think you are having sexual problems?

Psychological ____ Physical ____

When was the last time you had successful intercourse? ______________________________________

______________________________________________________

Are (or were) your erections:

Straight? _____ Curved? ____ Painful? ____

Describe your sex life before your current problem _________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Describe any treatment you have had for this problem, and include names and address of the persons
who have treated you:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________



For each of the following check Yes, No or NA (Not Applicable)

Do you get aroused under any of the following conditions?
Yes No NA
Early morning/ awakening from sleep ____ ____ ____
With the need to urinate ____ ____ ____
Manual stimulation - self ____ ____ ____
Manual stimulation - partner ____ ____ ____
Oral stimulation ____ ____ ____
Anal sex ____ ____ ____
Partner other than spouse ____ ____ ____
Erotic clothing on self or partner ____ ____ ____
Vacation times ____ ____ ____
Unusual places other than bedroom ____ ____ ____
Erotic books, magazines, videos ____ ____ ____

Are erections ever sufficient for
vaginal intercourse? ____ ____ ____

Is vaginal lubrication sufficient
for penetration? ____ ____ ____

Do you lose erections during intercourse? ____ ____ ____

Do you lose erections before ejaculation? ____ ____ ____

Are you still able to have an orgasm? ____ ____ ____

Does semen come out of your
penis normally? ____ ____ ____

Do you have any of the following conditions?
Yes No
Diabetes
Hypertension (high blood pressure)
Nervous condition
Thyroid problems
Cancer
Chronic Pain
Back problems
Poor circulation
Leg or calf pain with walking
Constipation
Difficulty urinating
Are you having any perimenopausal symptoms? Yes_____ No______

___________________________________________
___________________________________________
___________________________________________

Are you still having your period? Yes_____ No______

If yes, how many days do you bleed? __________

Have your periods changed recently? Yes_____ No______

If you have stopped your period, are you having any post-menopausal symptoms? Yes_____ No______

___________________________________________
___________________________________________
___________________________________________

Are you interested in natural hormone replacement? Yes_____ No______

Are you worried about recent reports about the dangers of hormone replacement? Yes_____ No______

If you have taken or are currently on hormones, please list them.

___________________________________________
___________________________________________
___________________________________________

Answer these signs of testosterone deficiency in women.

Yes No
1. Overall decrease in sexual desire/pleasure
2. Diminished energy and sense of wellbeing
3. Thinning and loss of pubic hair
4. Overall decreased arousability.
5. Decreased sensitivity to stimulation of the breasts.
6. Decreased sensitivity to stimulation of the clitoris.
7. Overall decreased capacity for orgasm.
8. Decrease in sexual dreams or fantasies.
9. No interest in making love.
10. My orgasm is diminished in intensity.
Have you ever had surgery on your
Yes No
Back
Rectum
Blood vessels
Colon
Genito - Urinary organs

Have you ever seen a psychotherapist about this or any other problem?

Yes No
If yes, please explain situation on back of this page.

How much alcohol do you consume? Include types, frequency and number of years.

__________________________________________________________________________________

__________________________________________________________________________________

How many packs of cigarettes do you smoke in an average day? How long have you smoked? If you have
stopped smoking, how long have you been a non-smoker?

__________________________________________________________________________________

__________________________________________________________________________________

How does your sexual partner view your problem? Do you talk about it? Are there relationship problems
brewing because of the sexual problem?

__________________________________________________________________________________

__________________________________________________________________________________

What treatment plans have you heard about?
Yes No
Psychological counseling
Penile implants
Hormone injections
Vibrators
Vacuum pumps
Urethral suppositories
Yohimbine, Viagra
Others
How old were you when you became sexually active with partners? ______

Have you ever been sexually abused? Yes No

Add any information that you believe to be helpful.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________


SECTION B: ECOLOGY QUESTIONNAIRE

Yes No
1. I live in a city full of noise and pollution.
2. I live near power lines.
3. I have plenty of fresh air and sunshine.
4. I drink and bathe in pure water.
5. I eat mostly organic fruits and vegetables.
6. I avoid chemicals like insecticides and cleaners.
7. I use aluminum cookware.
8. I avoid smoking and recreational drugs.
9. I minimize taking any over-the-counter or pharmacy drugs.
10. I use alcohol moderately.
11. I use natural soaps, underarm deodorants and toothpastes.
12. I recycle and conserve water, electricity, etc.
13. I rarely litter.
14. I honor other life forms - animals, birds, etc.
15. I use biodegradable products whenever possible.
16. I avoid products tested on animals.
17. I avoid eating packaged foods.
18. I practice safe sex.
19. I vote on matters to protect our environment.
20. I try and limit my intake of red meat.
Totals


FUNCTIONAL MEDICINE QUESTIONNAIRE

Point Scale

0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe

HEAD __________ Headaches

__________ Faintness

__________ Dizziness

__________ Insomnia Total ______


EYES __________ Watery or itchy eyes

__________ Swollen, reddened or sticky eyelids

__________ Bags or dark circles under eyes

__________ Blurred or tunnel vision Total _____
(does not include near or farsightedness)


EARS __________ Itchy ears

__________ Earaches, ear infections

__________ Drainage from ear

__________ Ringing in ears, hearing loss Total _____


NOSE __________ Stuffy nose

__________ Sinus problems

__________ Hay fever

__________ Sneezing attacks

__________ Excessive mucus formation Total ______

MOUTH/
THROAT __________ Chronic coughing

__________ Gagging, frequent need to clear throat

__________ Sore throat, hoarseness, loss of voice

__________ Swollen or discoloured tongue, gums, lips

__________ Canker sores Total _____


SKIN __________ Acne

__________ Hives, rashes, dry skin

__________ Hair loss

__________ Flushing, hot flashes

__________ Excessive sweating Total ______



HEART __________ Irregular or skipped heartbeat

__________ Rapid or pounding heartbeat

__________ Chest pain Total ______


LUNGS __________ Chest congestion

__________ Asthma, bronchitis

__________ Shortness of breath

__________ Difficulty breathing Total ______


DIGESTIVE
TRACT __________ Nausea, vomiting

__________ Diarrhea

__________ Constipation

__________ Bloated feeling

__________ Belching, passing gas

__________ Heartburn

__________ Intestinal/stomach pain Total ______


JOINTS/ __________ Pain or aches in joints
MUSCLE
__________ Arthritis

__________ Stiffness or limitations of movement

__________ Feeling of weakness or tiredness Total ______


WEIGHT __________ Binge eating/ drinking

__________ Craving certain foods

__________ Excessive weight

__________ Compulsive eating

__________ Water retention

__________ Underweight sores Total ______

ENERGY/ __________ Fatigue, sluggishness
ACTIVITY
__________ Apathy, lethargy

__________ Restlessness Total ______

MIND __________ Poor memory

__________ Confusion, poor comprehension

__________ Poor concentration

__________ Poor physical coordination

__________ Difficulty in making decisions

__________ Stuttering or stammering

__________ Slurred speech

__________ Learning disabilities Total ______


EMOTIONS__________ Mood swings

__________ Anxiety, fear, nervousness

_________ Anger, irritability, aggressiveness

__________ Depression Total ______


OTHER __________ Frequent illness

__________ Frequent or urgent urination

__________ Genital itch or discharge Total ______


GRAND TOTAL TOTAL _______



SECTION C: WORLD-VIEW WELLBEING QUESTIONNAIRE

(i) An Aliveness Questionnaire
Yes No
1. Do you feel a sense of balance in your life? ____ ____
2. Do you regularly enjoy hearty belly laughs? ____ ____
3. Do you live your dreams? ____ ____
4. Do you take time for solitude? ____ ____
5. Do you have at least two nutritious people in
your life? ____ ____
6. Do you feel the energy of optimum health? ____ ____
7. Do you have a spiritual practice in your life? ____ ____
8. Do you feel that your life matters? ____ ____
9. Does your recreation time re-create you? ____ ____
10. Do you have the courage to say "No"? ____ ____
Total "Yes": Responses = _________

(ii) A Meaning Questionnaire
Yes No
1. Is your life filled with enthusiasm, passion and joy? ____ ____
2. Do you agree there is little to fear in your life? ____ ____
3. Do you see the universe as essentially being friendly? ____ ____
4. Do you feel that your life is connected to something
larger than yourself? ____ ____
5. Do you often feel close to a spiritual presence? ____ ____
6. Have you had an experience that has convinced
you "God is real"? ____ ____
7. Do you believe that you are immortal? ____ ____
8. Is your life productive and full of meaning? ____ ____
9. Do you let your "inner voice" guide you rather
than the expectation of others? ____ ____
10. Do you see your death as a step in your evolution? ____ ____
Total "Yes": Responses = _________

(iii) A Purpose Questionnaire
Yes No
1. Do you wake up most Mondays feeling energized
to go to work? ____ ____
2. Do you have deep energy - feel a personal calling -- ____ ____
for your work?
3. Are you clear about how you measure your success
as a person? ____ ____
4. Do you use your gifts to add real value to people's
lives? ____ ____
5. Do you work with people who honor the values
you value? ____ ____
6. Can you speak the truth in your work? ____ ____
7. Are you experiencing true joy in your works? ____ ____
7. Are you making a living doing what you most love
to do? ____ ____
9. Can you speak your purpose in one clear sentence? ____ ____
10. Do you go to sleep most nights feeling "This was a
well-lived day?" ____ ____
Total "Yes": Responses = _________

(iv) A Context Questionnaire
Circle the correct answer


Billion Million Thousand Hundred
1. The universe is approximately how old? 15 10 8 500
2. The earth is approximately how old? 5 5 10 800
3. Humans are approximately how old? 2 5 500 100
4. When did farming begin? 1 2 10 20
5. When did history (writing) begin? 1 2 5 25
6. When did the English language begin? 1 1 10 9
7. When did humans first discover perspective - the ability to see 3-D? 1 3 6 7
8. When did humans develop a sense of "self" (self-reflective consciousness)? 1 2 5 7


Answer

9. Can you have "fear" without the concept of
linear time?


10. Do you have an awareness of a divine
Self?

PART IV

ALTERNATIVE MEDICINE QUESTIONNAIRES.

(Alternative Medicine Questionnaire depends on individual needs of client)

Section A: Traditional Chinese Medicine
Section B: Ayurvedic Medicine
Section C: Chiropractic Medicine
Section D: Anthroposophical Medicine
Section E: Naturopathic Medicine
Section F: Homeopathic Medicine

APPENDIX A

CAUTION: Before You Test Your Aerobic Capacity:

It is important to obtain a medical clearance before starting an exercise program or
testing your aerobic capacity. The following are the reasons one should see a doctor:

1. History of heart disease, including heart attack, cardiac arrest, valve disease, congestive
heart failure, myocarditis, or any other heart disease treated by a physician.
2. History of chest pain diagnosed by a physician as angina pectoris.
3. Any known cardiac dysrhythmias (abnormal heart beats) or conduction defects
4. History of stroke
5. Use of medications for the heart or blood vessels during the last 3 months, including medicine
for chest pain, dysrhythmias, congestive heart failure, or hypertension (high blood pressure). Among
these are beta blockers (propranolol), digitalis, quinidine, procainamide, and nitroglycerin, but if there
is a question about a medicine, check with your doctor.
6. Any acute infectious disease (colds, flu, virus, etc.).
7. Neuromuscular, musculoskeletal, or orthopedic disorders that would make walking uncomfortable
or dangerous.
8. Renal (kidney), hepatic (liver), or other metabolic problems.
9. Resting blood pressure greater than 160 mmHg systolic or 100 mmkg diastolic.
10. Previous medical advice not to exercise.
11. If any suspicion of yours that exercise may be harmful, do not begin an exercise program or test
your aerobic capacity.

Adapted from the Learn Program for Weight Control
By Kelly D. Brownell, Ph.D.


APPENDIX B: INSTRUCTIONS FOR MEASURING THE BIOMARKERS

A 'biomarker' is by definition a characteristic whose value, when measured in a large number of
individuals, correlates significantly to quality of life and longevity.

Although the first five "Biomarkers" listed in Section G are not true biomarkers, they represent
important indicators of how you are aging and how you will age in the future.

6. Blood Pressure
There are many opportunities to get your blood pressure measured. You or one of your family may
have a blood pressure monitor that you can use. They are inexpensive and can be purchased at man
y stores. You can often have your 'free' blood pressure measured at your local drug store. You should
record both the systolic and diastolic blood pressure. Record at least three different blood pressure
measurements.

7. Caries Index
There are 32 permanent teeth made up of four kinds of teeth: incisor, canine, premolar and molar.
Simply inspect each tooth. Have someone count those teeth that have "holes" or "fillings". The number of diseased teeth (caries) should be written down and recorded.

8. Body Mass Index
a. Record your weight in pounds (with no or minimal clothes - best done first on waking).
b. Record your height (without shoes) in feet and inches.

We will calculate your Body Mass Index (BMI).

9. Waist/Hip Ratio
Fat deposition about the waist and flank, as evidenced by a high ratio of waist to hip circumference, is
associated with a greater health risk than fat deposition on the hips. Use a tape measure around your
waist and record the number. Your waist is found just under your lower ribs - often in line with your belly button. Then measure the circumference of your hips - often this is the widest part of your body
(Put the first number over the second).

10. Auditory Threshold
Hold a watch to your ear. Discover how far away from the ear it is still heard. Have someone measure
this maximum distance. You can 'rub your fingers together' if you have a digital watch that is silent.

11. Aerobic Capacity
Construct a simple 12" high bench to step on (A few concrete blocks and a wooden plank placed on top will do). Take your Heart Rate for 1 minute before stepping up and down and record this (H.R. one).
Then step up and down for 3 minutes and immediately record your Heart Rate when finished (H.R. two).
Note: You should step up and down at rate of 24 steps/minute.

12. Basal Metabolic Rate
Record your: Age_____ Weight_____ Height_____ Sex_____

13. Muscle Strength
You will need to borrow two 5-lb dumbbells if you are a woman or two 10-lb dumbbells if you are a man.

a. Upper Body:

Male: Count the number of 'push-ups' you can do.
Female: Count the number of "half" push-ups you can do. A half push-up is done by pushing up with your arms with your knees bent (on all fours). Let your chest nearly touch the floor each time and then push up with your arms.

b. Lower Body:

Male: With a 10-lb dumbbell in each hand, squat down to a near sitting position (from standing upright). Count the number of squats you can do before you tire out.

Female: With a 5-lb dumbbell in each hand, squat down to a near sitting position (from standing position).
Count the number of squats you can do before you tire out.

14. Skin Elasticity
Simply pinch the skin on the back of your hand between your thumb and forefinger. How long does it take to flatten back out completely? Repeat three times and place an A, B or C with each recording?

a. 0-1 sec.
b. 2-5 sec.
c. 6-50 sec.

15. Axillary Temperature
Take your temperature for 3 days by placing a thermometer in your armpit before getting out of bed each morning for 3 days. Record all three temperatures.

16. Static Balance
Stand on a flat surface. Keeping your eyes open, lift your left foot if you are right handed (vice versa) about 6 inches off the ground while bending your knee at a 45-degree angle. Have someone time you (and catch you if necessary) to see how long you can do this without opening your eyes. Repeat this three times and record all three.

17. Visual Accommodation
Slowly bring a newspaper to your eyes until the regular-size letters start to blur. Have a friend measure the distance between the eyes and the paper with a ruler. Do this either without glasses on with glasses corrected for distance (not reading glasses). It is not how well you can read the print but at what point it starts to blur.

18. Vital Capacity
You need a candle and a box of matches. Light the candle and try blowing it out; keep moving the candle farther and farther away until you are unable to blow it out. Measure the distance between you and the candle.
Note: Try and have the candle at the same height as your mouth.

19. Reaction Time
Have a friend suspend an 18" ruler between your thumb and middle finger. Your friend lets the ruler go without warning and you catch it between your fingers as quickly as possible. Note: Place the ruler with the 1" mark level with the subject's fingers. Record the "number of inches" where the ruler is caught. (Repeat this three times and record all three markings).

20. Body Flexibility
Stand with your bare feet 6 inches apart. Legs should be straight - do not bend the knees. Now flexing at your waist, try and touch the floor. If you can easily touch the floor (no bouncing) mark a zero. Otherwise, have someone measure how many inches your fingertips are from the floor. Record this number.

 

NUTRACEUTICALS
Multivitamins
Norwegian Fish Oil
Thyroid
Omega 3 Fish Oil
Coenzyme Q Gel
L-Carnitine Fumarate
Cholesterol Control
Bone Support
Skin Health
Eye Support
RiboBoost

 

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