Number of Yes'
Do you drink less than 8 glasses of water each day?
*
Yes
No
Do you drink tap water from your house, filtered water from the refrigerator, or restaurants?
*
Yes
No
Do you drink bottled water?
*
Yes
No
Do you eat leafy green vegetables less than 5 times each week?
*
Yes
No
Do you exercise less than 3 days each week?
*
Yes
No
Are you more than 25 pounds overweight?
*
Yes
No
Do you have any sugar once a week? Ex. Chocolate, Candy, Soda, etc.
*
Yes
No
Do you lose train of though right in the middle of talking about something?
*
Yes
No
Is your memory worse than it was 10 years ago?
*
Yes
No
Do you have trouble remembering names?
*
Yes
No
Do you drink at least 1 normal size (8 ounces) cup of coffee a day?
*
Yes
No
Do you put sugar sweeteners in your coffee or teas?
*
Yes
No
Do you consume more than 3 alcoholic drinks a week?
*
Yes
No
Do you smoke or have you smoked for longer than 5 years or have constant exposure to second hand smoke?
*
Yes
No
Have you had any piercings or tattoos done anywhere?
*
Yes
No
Do you have more than 3 fillings in your mouth or do you have any current dental infections or cavities?
*
Yes
No
Do you have a history of migraines or headaches?
*
Yes
No
Do you take Aspirin or other Tylenol Like pain relievers weekly?
*
Yes
No
Do you have trouble getting or staying asleep?
*
Yes
No
Do you have medium to high stress at work or home?
*
Yes
No
Do you tend to notice what is wrong more than what is right?
*
Yes
No
Do you struggle with feeling sad or blue?
*
Yes
No
Do you struggle with worry?
*
Yes
No
Do you have trouble experiencing joy on a daily basis?
*
Yes
No
Do you have difficulty relaxing?
*
Yes
No
Is your energy level most days low?
*
Yes
No
Do you struggle with cravings?
*
Yes
No
Have you ever had a brain injury or been in a car accident?
*
Yes
No
Have you ever played any contact sports?
*
Yes
No
Do you experience any tingling or numbness?
*
Yes
No
Have you had any vision loss or reduction over the last 10 years?
*
Yes
No
Do you commute more than 30 minutes to work each day?
*
Yes
No
Do you wear any cosmetics?
*
Yes
No
Have you done any medical diagnostic testing like MRI, X-Rays, CT, PET, or SPECT?
*
Yes
No
Have you been diagnosed with any cancer or tumor?
*
Yes
No
Have you had any chemo therapy or drugs like it?
*
Yes
No
Are you on any medications?
*
Yes
No
Do you have a low sex drive?
*
Yes
No
Do you experience any allergies?
*
Yes
No
Name
*
First Name
Last Name
Email
*
example@example.com
**By providing your phone number, you agree on receiving text from our Center**
Phone Number
*
-
Area Code
Phone Number
Submit
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