Optimum Healthspan Institute

This form will be emailed to Dr Haffejie. Please fill in all fields

Full Name*

Email Address*

Your Phone*

Your Age*

Your Occupation

Date of birth

Your Weight

Your Height

Your Waist Circumference

Your Pulse(Heart Rate)

Your BMI

Past medical history
Family history of diabetes or heart disease(eg heart attack/angina/bypass surgery) or stroke? Details if yes.
Significant illness in the family (1st degree relatives) incl cancers - breast, prostate etc.
How old is your father?(if late at what age?)
What illnesses or complications has he suffered?
How old is your Mother?(if late at what age?)
What illnesses or complications did she suffer?
Brothers and sisters relevant history and complications
Medication you are currently taking incl. vitamins and mineral supplements
What problems are you experiencing at the moment(that you would like to get rid of?)
What are your main concerns regarding your health? Any immediate problems you need to address/get rid of?
How many hours do you sleep at night?
Can you stay up OFTEN till late at night eg. midnight without any problem?
What is the depth of your sleep?(is it very light, or quite deep i.e you could sleep through a cannon ball shot!)
Do you feel tired even after at least 8-10 hours of sleep, i.e adequate sleep does not seem to refresh/recharge you quickly?
How long does it take you to fall asleep at night?
How often do you wake up in the middle of the night or early hours of the morning?
How often do you pass urine at night?
When do you feel the best i.e most energetic? in the morning after you get up or in the evening after dinner?
What are your energy levels like when you wake up in the morning? Bad (Its a mission to get out of bed) Good (No problems getting going) Extremely good (Bouncing off the walls!)
What are your energy levels like by 10 am, 2 pm, 4pm and by the time you get home in the evening?
When do you feel the best (i.e most energetic) a)The moment you get out of bed b)30-45 min after getting up in the morning c)Later in the morning d)Midday e)Afternoon f)Evening(bedtime)
Is your face puffy in the morning?
Are your eyes puffy in the morning?
Is your skin: a)Normal b)Dry c)Oily?
Is your hair often very dry?
Are you experiencing hair loss?
If Yes in what distribution? eg all over, only in the front, only on the top, only at the back?
Describe your pubic and axillary hair. a)Never had any good growth ever (since puberty) b) Have good/normal volume of hair c)Had normal volume of hair but getting less/sparse ie less volume of hair over the last 10 years.
Do you feel light headed when standing for long periods of time eg in a bank que?
Do you OFTEN feel better lying down (less light headed and more energetic) than standing up?
Do you have problems OFTEN with night vision eg driving at night or difficulty seeing in the dark?
Are you very sensitive to stress i.e you are easily triggered into stress mode by often minor problems/incidents?
Are you able to listen to other peoples problems/complaints without easily becoming sensitive emotionally or do you become very emotional when listening to other peoples problems?
how would you describe your stress levels? if high what would you attribute this to?
Do you experience paronia fairly often (often suspicious about events, over protective eg over kids)?
Do you feel stressed even in the absence of apparent stress factors (i.e you feel stressed even when you have no reason to be stressed?)
Do you get very tired after stress or a stressful event or a stressful day?
Do you have outbursts of anger (i.e 1 or 2 minutes of excessive anger outburts?)
If yes, do you feel fatigued/tired after these outbursts?
Are you irritable?
What is your libido like?(interest in sex - NOT quality of sex or erections!)
Are you happy with your weight/body image? Do you see yourself as being overweight?
How often do you exercise? For how long? What type of exercise?
How many cigarettes do you smoke per day?
How much alcohol do you drink per day/per week?
What type of alcohol do you take?
How many cups of coffee do you drink per day? Caffeinated or decaf?
Can you easily tolerate more than 3 cups of strong caffeinated coffee per day?
Do you require coffee to keep you active during the day?
Do you have any mercury dental fillings? how many?
How many meals do you eat per day?
Describe what you eat in full detail during these meals as well as in between.
Do you crave sugar? How often?
Do you get hungry shortly after a meal or often hungry in between meals?
If yes what do you eat during these episodes of getting hungry?
Do you experience alot of a) bloatedness, b) burping, c) bad breath, d) flatulence (bad wind), e) abdominal cramps?
Are you a fast eater?
How often do you pass stools?
What is the consistency - soft / normal / often very hard / do your stools float?
How often do you pass water during the day?
If you have a few glasses of water, do you find that your bladder fills up quickly and that you have to urinate shortly after drinking a few glass of water?
Do you have any skin problems?

Females only to answer the following questions.

Do you have any children? how many?
Have you ever used a contraceptive pill? Which ones?
How long were you on each of the above?
Have you ever used hormone replacement therapy (pill for menopause?) which ones?
How many years have you been on each of the above?
Age of onset of menses / age of onset of menopause (if applicable)
Do you experience hot flushes? - how often? - how long do they last?
Have you had a mamogram(if over 40) - bone density scan?(if over 40)
Are your periods regular i.e every 28-32 days?
How many days do you bleed?
How heavy is the flow? / how many pads do you use per day? / do you bleed with clots? / do you experience swelling of your ankles, hands or fingers?
Describe your mood just before and during your period.
Do you experience severe swelling of your breasts during or before your period (current or in the past)?
Do you experience bloating or swelling in your tummy before or during your period(currently or in the past)?
Do you currently experience SIGNIFICANT period pain?
Have you experienced significant period pain in the past?

Contact Dr Haffejie at 011-805-3731/011-315-3283

Email : haffejie@gmail.com

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