Print Out Pages 1 through 6 NOW
for AGESCORE(TM) TEST TAKING
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Background Information:
I. The Agescore(TM) is a composite of two separate system tests for aging:
1.) Written tests: Genetic Factors/ Life Style Risks and
Fitness Test Analysis
2.) Laboratory Tests: (results from a Doctor’s office or a health fair) and
Hormonal Assay (blood work sent to Quest: Corning Reference Laboratory)
II. How to Score the Written Test
Complete the questions on the following pages by writing in a number between 1 and 7
in the box to the LEFT of the question. There are 32 questions to complete.
How to Complete the AGESCORE(TM) forms
When you have completed the 32 questions, copy the answers in the box to the TEST SCORE SHEET on page 5. Only pages (#5) and (#6) will be returned to us by mail, fax, or e-mail for scoring. The AGESCORE(TM) and 12-15 page report will be mailed to the address you enter on page #6.
Where to Send the Completed Forms:
Mail to:
E-mail to:
The AGESCORE (TM) WRITTEN TEST:
HEALTH RISK ANALYSIS: PERSONAL QUESTIONNAIRE
Instructions: Complete the following questions by writing a number between 1 and 7
in the box next to the questionnaire number.
Section I: Activity Evaluation
1. [ ] How many times per week do you exercise more than 25 minutes
per exercise session, sweat, and bring your heart rate to 110-130 range?
[1] 3 or more times per week
[2] Twice a week
[3] No regular exercise plan
2. [ ] Indicate your current type and level of physical activity.
[1] Strenuous activity: running, racquetball, advanced aerobic, race.
[2] Heavy activity(tennis, weight lifting, rowing, swimming, aerobics)
[3] Moderate activity (walking, stationary bike, calisthenics
[4] Light (low level walking, beginning aerobics, swimming)
[5] No exercise
3. [ ] Warm-Up/Cool Down: Do you stretch and warm-up prior
and allow for adequate cool-down after each exercise session?
[1] Both, yes
[2] Warm -up only
[3] Cool-down only
[4] Sporadically
[5] Never
4. [ ] Carbohydrate Consumption: Processed sugar: Convenience foods.
Complex Carbohydrates: natural fruit, vegetables, whole grains.
[1] Eat only natural sugars and complex carbohydrates
[2] Eat primarily natural sugars, and complex carbohydrates
[3] Eat both about the same
[4] Nearly always eat processed sugars and simple carbohydrates
5. [ ] Fat Consumption: High fat: cheese, whole milk, ice cream,
fried foods, animal fats, red meat, lard, solid fat. Low fat=non-fat milk,
chicken, turkey, fish, tofu, beans, vegetables and fruits.
[1] Eat only low fat or none at all
[2] Eat primarily low fat products, some high fat
[3] Eat both about the same
[4] Eat mostly high fat products, some low fat
[5] Nearly always eat high fat products
6. [ ] Preparation: High fat:frying, butter. Low fat:bake, veg. oils.
[1] Food cooked using only low fat methods
[2] Primarily low fat
[3] Food cooked both ways
[4] Food mostly cooked with high fat
[5] Food nearly always cooked using high fat methods.
7. [ ] Cereal Grain Products: Refined grain products: White breads, rolls, pancakes, white rice, breakfast cereals, baked goods. Whole Grain:
whole grain breads and rolls, brown rice, oatmeal and whole grain cereals.
[1] Only whole grain
[2] Primarily whole grain
[3] Eat both the same
[4] Eat mostly refined grain
[5] Always eat refined grain
8. [ ] Convenience Foods: How often do you eat fast food meals
(hamburgers, tacos, fried chicken, hot dogs, French fries, milk shakes)
[1] Seldom or never
[2] Few times per month
[3] Several times per week
[4] Nearly every day
9. [ ] Intake of Salt: How often do you add salt to your foods? Eat pickled/salty foods?
[1] Seldom or never
[2] Occasionally
[3] Regularly
[4] Prefer salt, add salt in cooking food.
10. [ ] Daily meals:How often do you eat 2+ meals/day on schedule?
[1] Eat at least 2 meals every day on schedule
[2] Almost every day
[3] Sometimes
[4] Rarely or never
11. [ ] Snacks: How often do you consume between meals snacks? candy bars, soft drinks, cookies, ice cream? (fruit and vegetables do not count!)
[1] Rarely or never
[2] A few times per week
[3] Once/ twice weekly
[4] Snack daily
12. [ ] Drinking Days: On average, how many days/week do you consume alcoholic beverages?
[1] Not at all
[2] 2 days or less per week
[3] 3 days or less
[4] More than 4
13. [ ] Number of Drinks/day you drink alcoholic beverages?
[1] Not at all in the last year
[2] One drink
[3] Two to three drinks
[4] Three to four
[5] Five or more
14. [ ] Drugs: How often do you use drugs/medication that affect
your mood, help you relax, or sleep?
[1] Never
[2] Rarely, few times/year
[3] Monthly
[4] Weekly
[5] Daily
15. [ ] Caffeine: How often do you consume caffeine?
[1] Never
[2] Occasionally, not daily
[3] Less than 2 cups/day
[4] 2-4 cups
[5] More than 4 cups daily
16. [ ] Smoking Status:
[1] Never
[2] Quit smoking 10 or more years ago
[3] Quit less than 10yrs
[4] Smoke pipe or cigar only
[5] Smokes up to 10 cigarettes/day
[6] Smokes more than 10 cigarettes/ day
17. [ ] Smokeless Tobacco: Do you use smokeless tobacco?
[1] No
[2] Yes
18. [ ] Stress/Coping/Anxiety: Which response best describes
how you are feeling about stress in your professional and personal life.
[1] Seldom stressed, coping very well
[2] Sometimes stressed, coping fairly well
[3] Often stressed, occasionally having trouble coping
[4] Heavily stressed, often have trouble coping
[5] Excessively stressed, unable to cope
19. [ ] Energy level: Felt tied, worn out, or exhausted during the
past month for no apparent reason? (After 8hrs sleep, still feel tired?)
[1] Seldom or never feel tired
[2] Only occasionally
[3] Less than half the time
[4] The majority of the time
20. [ ] Sleep: On the average, do you get at least 7-8 hours sleep daily?
[1] At least 6 out of 7 days
[2] Four out of 7 days
[3] Half the time
[4] Only occasionally
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21. [ ] Seat belts: When riding in a care how often do you wear seat belts?
[1] Always were a seat belt
[2] Majority of the time
[3] Less than half
[4] Only occasionally wear seat belt
22. [ ] Clinic Visits: How many visits to a clinic in the past year? (Doctor’s office, emergency room, psychiatrist, psychologist, chiropractor)
[1] None, other than annual check-ups
[2] One to two visits
[3] 3 -6 visits
[4] 6-9 visits
[5] Ten or more
23. [ ] Sick days: How many sick days did you miss from work due to
sickness or injury during the past 12 months?
[1] None
[2] 1-3
[3] 4-6
[4] 7-9
[5] 10 or more
24. [ ] Routine Check-Up or Physical:How often for routine screening?
[1] At least once per year
[2] At least every two years
[3] No screening for at least 2 years
[4] None for five years
[5] Never
25. [ ] Mammogram: Female over 40, have a mammogram every 2 years?
[1] Yes
[2] No
[3] Not applicable
26. [ ] Prostate Screening: Male over age 50, annual prostate exam?
[1] Yes
[2] No
[3] Not applicable
27. [ ] Colon-Rectal Screening: Over age 40, annual rectal screening?
[1] Yes
[2] No
[3] Not applicable
28. [ ] Cancer Warning Signs:
[1] None
[2] Change in mole or freckle
[3] Chronic indigestion
[4] Unusual bleeding or discharge
[5] Unexplained weight loss
[6] Chronic cough/sore throat
[7] Thickening or lump in breast or elsewhere
Genetic Factors:Direct family members refers to mother, father, brothers,
sisters,, aunts, uncles, first cousins, and grandparents.
29. [ ] NUMBER of direct family members that have DIED from or had
CORONARY HEART DISEASE diagnosed BEFORE age 60.
30. [ ] NUMBER of direct family members that have DIED from or had
CORONARY HEART DISEASE diagnosed AFTER age 60.
31. [ ] NUMBER of direct family members diagnosed with DIABETES MELLITUS.
32. [ ] NUMBER of direct family members who have been diagnosed with
cerebrovascular disease or stroke.
***Copy the Answers from the blocks on the left of your question to
the numbered blocks on the bottom of this page (page #5).*****
Bottom of Page 5
The AGESCORE (TM)
Midwest Medical Group, P.C.
29355 Northwestern Hwy. Suite 120
Southfield, Michigan 48034
phone: 1(248)358-4357
1(800)612-5892
PART 1: WRITTEN TEST: SCORE SHEET
1. [__] 7. [__] 13. [__] 19. [__] 25. [__] 29. [__]
2. [__] 8. [__] 14. [__] 20. [__] 26. [__] 30. [__]
3. [__] 9. [__] 15. [__] 21. [__] 27. [__] 31. [__]
4. [__] 10. [__] 16. [__] 22. [__] 28. [__] 32. [__]
5. [__] 11. [__] 17. [__] 23. [__]
6. [__] 12. [__] 18. [__] 24. [__]
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Part 2: THE DOCTOR'S OFFICE: DATA & MEASUREMENTS
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Name:____________________________ Date: __(mo)/___(dy)/___(yr)
SS no: or (9 digit id. number)___ ___ ___ ___ ___ ___ ___ ____ ____
Mailing Address: _________________________________________
City,State,Zip: _______________________ ____ ___________
E-mail address: _________________Fax number:( )_____________
Body Measurements
Weight:(pounds) ______ Sex M F Age ___ birthdate:___ /____/19___
Height:(inches) ______ Blood pressure___/_____ heart rate: ________
Waist: (inches) ______ Hip(inches):_______ Wrist(inches):_________
Exercise, Weight lifting Testing
Time to race 1.5 miles(minutes:sec) ___:___ Sit Ups in 30 seconds:______
Distance from touching toes(inches) ___
Grip Strength(pounds): Left: _______ Right: (pounds)___________
Maximum arm weight lift (biceps only, elbows on table): ___________
Maximum body weight lift (using arms and legs:”Dead lift): ___________
Office Laboratory Tests
Cholesterol: _______ H.D.L.:______ Ratio Chol/HDL:________
Triglycerides: ________ Glucose:_______ L.D.L.:____________
(spirometry ) Forced Expiratory Vital Capacity: ______(liters/min)
Total Ventilatory Capacity _______________________(liters)
======================================================================================
Check for the Nearest Drawing Station with
Part 3:
Hormonal Laboratory Tests:
Quest Labs: Corning Nichols Institute,
33608 Ortega Highway,
San Juan Capistrano, California 92676
1(800)553-5445
Complete Blood Count
SMA-12
Hormonal Assays
D.H.E.A.-S (dehydroepiandrosterone sulfate) ug/dl _________
Thyroid Stimulating Hormone ______ Free T3,Free T4 _________
Testosterone (total) ug/dl ______ Testosterone (free)_________
Estradiol ug/dl ______ (women;week before menstruation)
Somatomedin C (IGF-1) (Corning Lab,CA.) ______
Sex Hormone Binding Globulin____________
Osteoporosis Screen (Dual Photon Densitometry) (optional) _________
page 6
AGESCORE (TM)
Midwest Medical Fitness, P.C.
29355 Northwestern Hwy. #120
Southfield, Michigan 48034
REGISTRATION FOR THE AGESCORE(TM) INTERPRETATION
PLEASE COMPLETE ALL THE FOLLOWING INFORMATION
name_________________________________________ (tested individual)
address_______________________________________ (where report mailed)
city/state/zip___________________________________
bill to credit card: [ ] VISA [ ] MasterCard [ ] Discover
card number: _________ _________ __________ ____________
expires: _________ _________
We confirm all purchases with the credit company.
We will call you to confirm purchase:
phone number: ______ ___________________________
or Email address: ___________________________
If there are any questions, you may call us during office hours at:
1(248)358-3433
However, in depth discussions are available only through the:
CONSULT SERVICE.
.............................AGESCORE (TM) INDEX......................................
...............INTERPRETING YOUR HEALTH RISK ANALYSIS.........................
name____________________ date________________
1. GENETIC/ENVIRONMENTAL RISK FACTORS:
Non-controllable low risk normal risk high risk
Genetic, non-controllable risk factors, include the family history of coronary heart disease, diabetes, strokes and premature deaths. These factors are by far the most predictive of the possibility of longevity and quality life.
Gray hair is a minor, but readily recognized factor. Premature graying before 30 is associated with an increased risk of premature heart disease and earlier demise as is premature balding.
Skin test elasticity roughly correlates with more advanced aging.
Emotional Quotient low risk normal risk high risk
Emotional factors related to our social ability may have a direct correlation to lifespan. Those who are depressed and have limited friends and social acquaintances have an increased risk of suicide, as well as mental and physical illness. Divorced men live on an average 10 years less than married men after age 50.
Controllable low risk normal risk high risk
Life-style factors include exercise frequency and type, carbohydrate-fat-junk food consumption, salt-caffeine intake, and past and present use of drugs, alcohol and smoking. Lastly, your stress-coping skills, number of sick days needed, and routine medical check-up history are recorded. Life-style changes can significantly improve longevity.
2. BODY COMPOSITION:
Lean Body Percentage: low risk normal risk high risk
Lean Body Mass includes all body components except fat. Approximately 5% fat is necessary for proper physical health. If you consume more calories than your body burns, the excess calories are stored as Body fat. Excess Body fat “frequently results in a significant impairment of health.” For men the range is 12-18%; for women, 15-25%. Your body fat percentage is a reflection of your diet and exercise lifestyle.
Fitness Test Analysis low risk normal risk high risk
A weighted blend of all the Fitness Test Scores that have been inputted.
The score reflects an overview of your Personal Fitness Level normalized for your age and sex. The individual tests are listed below:
Abdominal endurance: sit-ups in one minute ___________
Flexibility test: sit and reach test trunk flexibility___________
Grip strength: left/ right hand pounds(L)______ (R) _________pounds
Static Biceps: curl strength, arms at 90*angle __________pounds
Static Dead Lift: shrug strength; standing, pull up __________pounds
Oxygen Saturation: at rest (time to complete 1.5 miles)___________
3. CARDIAC MEASUREMENTS:
Resting heart rate pulse: ______ blood pressure: _____/ _______
Resting heart rate is a reflection of cardiac health and workload.
Systolic blood pressure is the highest pressure reached in your arteries.
Diastolic blood pressure is the lowest pressure reached in your arteries.
VO2 max: calculated from a treadmill stress test_________ ml O2 /kg.min.
VO2 max, maximal oxygen uptake, measures the oxygen consumed during maximal prolonged exercise. It is an international reference standard for physical fitness. The most specific calculations are made from the treadmill test. A less accurate field test is performed by timing a run of 1.5 miles on a tract.
4.CHOLESTEROL/ GLUCOSE SERUM LEVELS:
Ratio of Cholesterol/ HDL __________ expected ratio: Chol/HDL:<4
HDL and Cholesterol are each vital components.
Cholesterol ______ expected serum Chol level: <200 ______
Reduction of dietary fat and cholesterol will directly reduce blood cholesterol, leading in improved arterial circulation.
HDL ______ expected HDL level: male 40 female: 60______
High Density Lipo-protein (HDL) is a protein substance found in the blood. Exercise increases HDL.
LDL _______ expected serum LDL level: <140________
Low Density Lipo-proteins (LDL) account for approximately two-thirds of your total cholesterol level. Exercise and diet are beneficial.
Trigylcerides: ______expected serum TriG level: __________________
Glucose: _____expected serum level: <90______________
Glucose is a measure of blood sugar. With aging, there is an increased level.
5. PULMONARY MEASUREMENTS:Pulmonary Functions: measured by spirometry
Forced expiratory volume (FEV1) ________ expected:_________ liter/sec or %
Vital Capacity (VC) ___________ expected VC__________________
VC is the total volume of air expelled form the lungs by a maximal expiration.
6. HORMONAL PARAMETERS:
DHEA __________ug/dl expected serum DHEA__________________
DHEA is an adrenal hormone that reaches its maximal value in the 20's.
Testosterone _____ug/dl expected serum TESTOSTERONE _______
Testosterone, the primary male hormone, is also present in small amounts in the female. Estradiol ______ug/ml expected serum ESTRADIOL__________
Estradiol, the primary female hormone, is also present in small amounts in the male. .
Insulin-like Growth Factor-I _____ expected serum IGF-1 ___________
IGF-1,manufactured in the liver,is related to human growth hormone level.
Pregnenolone ______ expected serum Pregnenolone _________
Pregnenolone is the precursor to DHEA. Pregnenolone may be related to memory.
Osteoporosis Testing (optional): relates the degree of thinning of bone.
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To receive the INTERPRETATION, send pages #5 and #6
with a check or money order for $49.95 to the address below.
You may fax, mail or e-mail the forms
from page #5 and #6 to
If you include a copy of your credit card and a photo-id and authorize billing.
Be Sure to Include a Return Address
to receive your 12-15 page report!
AGESCORE(TM)
Midwest Medical Fitness, P.C.
29355 Northwestern Hwy. Suite 120
Southfield, Michigan 48034
phone (248)358-3433
E-mail address: usdoctor@usdoctor.com
fax number: (248)358-2513
CONSULTATION SERVICES AVAILABLE
To Discuss the results of these tests further,
you may CONSULT the USDOCTOR on the INTERNET
The information in this newsletter does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice.
The materials within this newsletter are copyrighted under the statutes of the State of Michigan. For additional copies contact:
Edward M. Lichten, M.D., P.C.
29355 Northwestern Hwy, Suite 120,
Southfield, Michigan 48034
phone (248)358-3433. ***
Correspondence by E-mail to:
USDOCTOR@USDOCTOR.COM
office fax: (248)358-2513
AGESCORE(TM)
Installed: July 1, 1996
Updated: May 2, 1997