BioLife Neuroscience Check Your Brain Questionnaire (305)-707-7404

Instructions: Check the column that best describes you.

	Almost Never	Sometimes	Often
I am distracted easily
I feel anxious or nervous
I feel irritable or angry
I have tremors or shaking
I have difficulty falling asleep or staying asleep
I forget the names of people or things
I have racing thoughts
I am disorganized
My thinking ability seems slower than usual
My reaction time seems lower than usual
I have headaches or aches and pains
I have trouble concentrating
I have trouble finding the right word
I have a loss of interest in some activities
I have trouble understanding what I read
I have distorted hearing or loss of hearing
I stumble or feel off balance when walking
My memory worsened in the past few years
I forget appointments and important events
I misplace personal items? (keys, wallet, purse, etc.)
I have trouble remembering to take medications, or keeping track of medication schedules
I have difficulty driving, or I am concerned about my driving ability
I ask the same question, or repeat the same thing (or story) several times to the same people
I become confused or disoriented in new, unfamiliar places
I have difficulty or confusion with operating familiar appliances? (smartphone, TV remote control, computer, microwave, dishwasher, etc)
I sometimes forget the correct month or year
I have difficulty paying bills & managing personal finances
I sometimes confuse the names of family members or close friends
I have trouble recognizing familiar people