Brain Function Quiz

1

Do you have difficulty planning and organizing?

yes

No

2

Lack of motivation, enthusiasm, interest and drive?

yes

No

3

Do you have mental fatigue?

yes

No

4

Do you have daily pain? daily pain is hard on your brain

yes

No

5

Do you have episodes of depression?

yes

No

6

Do you have hypersensitivities to touch or pain?

yes

No

7

Do you have difficulty with writing?

yes

No

8

Do you have difficulty interpreting speech with background or scattered noise?

yes

No

9

Is your memory less efficient?

yes

No

10

Do you misplacement things?

yes

No

11

Do you have any balance problems?

yes

No

12

Do your hands shake when reaching for something?

yes

No

13

Do you have digestive issues?

yes

No

14

Do you have sensitivites to bright or flashing lights?

yes

No

15

Score

16

Your Score is {typeA}/35

17

Would you like to improve your brain function?* This field is required.

Yes

No

18

Where should we send your solutions for improving your brain?* This field is required.

example@example.com

19

Name

First Name

Last Name

20

Phone Number* This field is required.

Area Code

Phone Number