Patient Data Template — Eternity Health

Section 1 · Required

Patient basics & goal

The few essentials every analysis starts from.

Full name

Date of birth

Sex at birth (M / F / X)

Height & weight

Phone

Your #1 healthspan goal

More energy day to day Stay sharp & independent for decades Reverse a worrying lab trend Recover & rebuild after surgery Live well past 100

Section 2 · Medical test results

The full biomarker panel

Enter whatever results you have. Each marker maps into one or more body systems in your digital twin. The target column is the general optimization range we steer toward — your clinician interprets your numbers in context.

🧬GeneticOptional

Test / marker	Units	Target
APOE genotype / risk	e2/e3/e4	No e4 allele
CAD polygenic risk score	percentile	Low
Cancer polygenic risk score	percentile	Low
Protective longevity variants	count	Higher

⏱️Epigenetic clocksOptional

Test / marker	Units	Target
DunedinPACE (pace of aging)	ratio	< 0.80
PhenoAge acceleration	years	≤ 0 (younger)
Telomere length	percentile	≥ 75th

🩸Metabolomic / blood panelRequired

Test / marker	Units	Target
ApoB	mg/dL	< 60
Lp(a)	nmol/L	< 40
LDL-C	mg/dL	< 70
HDL-C	mg/dL	≥ 55
Triglycerides	mg/dL	< 90
HbA1c	%	≤ 5.4
HOMA-IR (fasting insulin + glucose)	index	< 1.0
hs-CRP	mg/L	< 0.5
eGFR (kidney)	mL/min	≥ 90
Liver ALT / GGT	U/L	< 20
Homocysteine	µmol/L	< 8
IGF-1	ng/mL	110–150
Omega-3 index	%	≥ 8

🩻Scans / functionalOptional

Test / marker	Units	Target
VO₂max	mL/kg/min	≥ 48
Coronary calcium (CAC)	Agatston	0
Grip strength	percentile	≥ 75th
Bone density (DEXA)	T-score	≥ 0

⌚WearablesOptional

Test / marker	Units	Target
Resting heart rate	bpm	≤ 55
HRV (rMSSD)	ms	≥ 50
Sleep quality	percentile	≥ 80th
Daily activity	k steps	≥ 8
CGM glucose variability	CV %	< 15

🦠MicrobiomeOptional

Test / marker	Units	Target	Your value
Gut microbiome diversity	percentile	≥ 75th

Section 3 · Intake questionnaire

Your history, lifestyle & inner life

Numbers tell us where the body is; this tells us why — and where the constraint really sits. Following Dr. Simpson's Era III model, we ask about the body, the mind, and your inner state.

Medical history

Current diagnoses / chronic conditions

Current medications & doses

Supplements you take

Past surgeries / major events

Allergies

Family history (longevity, heart disease, cancer, dementia, diabetes)

Lifestyle — body (Era I)

Exercise — type, days per week, zone-2 & strength?

Typical diet pattern

Omnivore Mediterranean Low-carb / keto Plant-based Other

Processed food, alcohol & caffeine — typical week

Sleep — hours/night, quality, snoring or apnea?

Tobacco / nicotine

Never Former Current

Mind & stress (Era II)

Perceived stress over the last month (1 low – 10 high)

Mood & anxiety — anything you'd flag?

Do you practice anything for stress (breathwork, meditation, HRV)?

Energy & cognition day to day

Inner life & meaning (Era III)

Optional, and as brief as you like — but often the deepest constraint. Share only what you're comfortable with.

How strong is your sense of purpose / meaning right now?

Quality of your close relationships & social connection

Do you often feel isolated or lonely?

Rarely Sometimes Often

Your relationship to aging and mortality — any fear or unease you'd want addressed?

What does a long, healthy life make possible for you?

For demonstration & intake only. Eternity Health's Human Digital Twin is an educational decision-support tool, not a medical device, and this template does not provide medical advice or diagnosis. Target ranges are general longevity-optimization references and may not be appropriate for your individual situation, so always interpret results with a qualified clinician. Bring this completed template to your consultation, or fill the Your value column of the Excel template and upload it directly in the Digital Twin demo.