RootSignal™ · FNDATN Functional Medicine

Your Longevity Internal Function Evaluation (LIFE)

A few minutes now saves time at your visit. Your answers are read personally before you arrive and shape how your results are interpreted — there are no right or wrong answers.

About you

First name *

Last name *

Email *

Phone *

Age *

Sex

What brought you in? (optional)

Lifestyle & health

This helps your clinic read your scan accurately — some medications and habits change the reading. Questions marked * are required.

Tobacco / nicotine *

Alcohol (drinks / week) *

Exercise (days / week) *

Exercise intensity *

Cannabis / marijuana *

Perceived stress *

Typical sleep (hrs / night) *

Current prescription medications *

I don’t take any prescription medications

Add each one so the spelling is right — or check the box above if you take none.

Do you take any of these types? (optional — helps us read your scan)

Blood-pressure / heart-rate (beta-blocker)metoprolol, atenolol, propranolol, carvedilolBlood pressure (calcium-channel blocker)diltiazem, verapamil, amlodipineOther blood-pressure medicationlisinopril, losartan, hydrochlorothiazideAntidepressant / anti-anxietysertraline, fluoxetine, escitalopram, amitriptylineAntihistamine, sleep aid, or bladder medicationdiphenhydramine (Benadryl), hydroxyzine, oxybutyninADHD / stimulantAdderall, Vyvanse, methylphenidateThyroid medicationlevothyroxine (Synthroid), liothyronine

Diagnosed medical conditions

High blood pressureDiabetes or prediabetesThyroid disorderHeart conditionAutoimmune or inflammatory conditionAnxiety or depressionDigestive disorder (IBS, IBD, reflux)Sleep apnea

Supplements you take regularly

Add each one — pick from the list, or type your own and choose “Add”.

Your environment & exposures

One more minute — everyday surroundings affect the systems we measure. Answer what you know; skip anything you’re unsure of.

Home environment overall (air, water, dust)

Water damage or visible mould at home

Home built before 1978

Primary drinking water

Pesticides / herbicides (home, lawn, pets)

Near heavy traffic, industry, or crop spraying

Workplace chemicals, fumes, dust, or metals

Hobbies (solvents, paints, welding, ceramics)

Protective equipment when exposed

Personal care & cleaning products

Food heated or stored in plastic; non-stick cookware

Bowel movements

New flooring, cabinetry, paint, or furniture (past 12 mo)

Gas stove and/or attached garage

Lives near a golf course

Plays golf

Community pool or hot tub use

Nail or hair salon

Dry-cleaned clothing

Section 1

Over the last month, how much has each been true for you?

I feel tired even after a full night's sleep

I feel wired, anxious, or 'on edge'

I crash in the afternoon or need caffeine to function

I have trouble falling or staying asleep

Section 2

Over the last month, how much has each been true for you?

Low libido or changes in sexual functionNone

NoneMildModerateSevere

Low libido or changes in sexual function

Mood swings, irritability, or PMS-type symptomsNone

NoneMildModerateSevere

Mood swings, irritability, or PMS-type symptoms

Unexplained changes in body temperature (hot/cold)None

NoneMildModerateSevere

Unexplained changes in body temperature (hot/cold)

Thinning hair, dry skin, or brittle nailsNone

NoneMildModerateSevere

Thinning hair, dry skin, or brittle nails

Section 3

Over the last month, how much has each been true for you?

Difficulty losing weight despite diet and exercise

Strong sugar or carbohydrate cravings

Energy dips or shakiness between meals

Increased belly fat over the last year

Section 4

Over the last month, how much has each been true for you?

Low mood, flatness, or loss of motivationNone

NoneMildModerateSevere

Low mood, flatness, or loss of motivation

Brain fog or difficulty concentratingNone

NoneMildModerateSevere

Brain fog or difficulty concentrating

Feeling overwhelmed by everyday stressNone

NoneMildModerateSevere

Feeling overwhelmed by everyday stress

Memory lapses or mental fatigueNone

NoneMildModerateSevere

Memory lapses or mental fatigue

Section 5

Over the last month, how much has each been true for you?

Bloating, gas, or discomfort after meals

Irregular bowel movements (constipation/looseness)

Food sensitivities or reactions

Heartburn or reflux

Section 6

Over the last month, how much has each been true for you?

Joint aches or stiffnessNone

NoneMildModerateSevere

Joint aches or stiffness

Frequent headachesNone

NoneMildModerateSevere

Frequent headaches

Skin issues (breakouts, rashes, eczema)None

NoneMildModerateSevere

Skin issues (breakouts, rashes, eczema)

Getting sick more often than you'd likeNone

NoneMildModerateSevere

Getting sick more often than you'd like

Section 7

Over the last month, how much has each been true for you?

Strong reactions to perfumes, cleaning products, exhaust, or other chemical smells

Symptoms that start or worsen within a day or two of a chemical exposure, and ease once you're away from it

Headaches, brain fog, or nausea in specific buildings or rooms

Multiple food, medication, or environmental sensitivities

Recent life events

Check any you've experienced in the past 12 months.

Death of a spouseDivorceMarital separationJail term or imprisonmentDeath of a close family memberPersonal injury or illnessMarriageDismissal from workMarital reconciliationRetirementChange in health of a family memberPregnancySexual difficultiesGain of a new family memberBusiness or work readjustmentChange in financial stateDeath of a close friendChange to a different line of workChange in frequency of arguments with spouseMajor mortgageForeclosure of a mortgage or loanChange in responsibilities at workSon or daughter leaving homeTrouble with in-lawsOutstanding personal achievementSpouse begins or stops workBegin or end schoolChange in living conditionsRevision of personal habitsTrouble with bossChange in work hours or conditionsChange in residenceChange in schoolsChange in recreationChange in church activitiesChange in social activitiesMinor mortgage or loanChange in sleeping habitsChange in number of family get-togethersChange in eating habitsVacationChristmas or a major holidayMinor violations of the law

Your answers are private and shared only with your clinic.