Brain Fitness Score @limitlessbrainlab

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Date* This field is required.

Date

2

Name* This field is required.

First Name

Last Name

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Which of the following most accurately describes you?* This field is required.

Male

Female

5

BMI (Body Mass Index)* This field is required.

Obese ( greater than 30)

Underweight or overweight

Healthy

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Drag and drop a score from 1 to 5 from lowest to highest how you have felt last week in the forthcoming questions.

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I have been full of energy for the entire day.(1- Not at all, 5- On top Energy)* This field is required.Describe your levels of energy on a scale from 1 to 5. 1 is the least energy and 5 is the most energy

8

I get easily distracted.( 1-Never & 5-Always)* This field is required.How often do you get distracted? Use it as a scale and answer between 1 to 5.

9

I feel quite anxious and stressed most times. ( 1- No stress or anxiety and 5- Some level of stress and anxiety is always present)* This field is required.On a scale from 1 -5, describe your level of stress and anxiety.

10

I have been struggling with brain fog ( 1-No fog and 5- Most times )* This field is required.On a scale from 1 - 5, describe your level of fog.

11

I have been struggling to remember things (1- No struggle and 5- Always struggle)* This field is required.On a scale from 1 - 5, describe the level of memory difficulty.

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Do you take Omega 3 tablets OR Eat 2 portions of oily fish weekly?* This field is required.Omega 3 is essential for brain's functions.

YESNO

13

Eat 2 portions of red meat a week OR take a daily supplement with at least 25mcg of vitamin B12 ?* This field is required.Vitamin B12 is often low in vegetarians.

YESNO

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Let us now see your daily habits. Answer the next set of questions in the number of days that you perform a certain practice. For e.g, if asked how often you meditate? Write the total number of days you practice meditation from 0 to 7 days.

15

Practice Meditation or Mindfulness for at least 10 minutes per day?( 0- 7 days)* This field is required.Answer 0 for no meditation at all and 7 for all the days of meditation.

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Being active for 20 minutes or more per day. Activities can include walking, yoga, gym workouts etc. (0-7 days)* This field is required.Any physical activity is counted as being active.

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Drink more than two liters of water per day ( 0 -7 days)* This field is required.Each day, ideally you should be drinking 2 to 3 liters of the water.

18

Drink two or more any alcoholic drinks per day? ( 0-7 days)* This field is required.Alcohol makes the brain slower and age faster.

19

Smoke any kind of tobacco in a day? ( 0-7 days)* This field is required.

20

Do you take any prescription medication, or other drugs that affect the brain? ( 0-7 days)* This field is required.

21

How satisfied are you with your brain care habits over the last week?

22

How would you rate your sleep ( 1 is pretty bad and unrestful & 5 is Excellent)* This field is required.

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How connected do you feel with your friends or family? ( 1- Not connected and 5- Well connected)* This field is required.

24

How healthy would you rate your food choices, particularly in relation to the brain? Eating fresh fruits, less sugar, good vitamin rich food helps the brain health. (1- Not good 5- Very good and healthy)* This field is required.

25

Describe honestly your caffeine use: coffee, energy drink, etc?* This field is required.

Coffee and energy drink: 1-2 per day

3 to 5 per day

6+ per day

No caffeine use

26

Have you been diagnosed with Hypertension(High BP)* This field is required.

YESNO

27

Have you been diagnosed with heart issues?( Ischemic heart disease)* This field is required.

YESNO

28

Have you been diagnosed with high cholesterol? (Hyperlipidemia)* This field is required.

YESNO

29

Have you been diagnosed with Diabetes(High sugar)* This field is required.

YESNO

30

I have been diagnosed with hearing loss or I believe I have some hearing loss* This field is required.

YESNO

31

Have you injured your head and had concussion of the brain?* This field is required.Did you have any head traumas in the past?

No concussion

Concussion with no loss of consciousness

Concussion with loss of consciousness

32

Do you have concerns about the memory loss?* This field is required.

Extremely concerned

Moderately concerned

Somewhat concerned

Slightly concerned

Not concerned at all

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Final question- considering all things, would you say your health is?* This field is required.

Excellent

Very Good

Good

Fair

Poor

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Phone Number* This field is required.Please do write your phone number with country code.

Please enter a valid phone number.

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Total:The scores above 60 are ROCKING BRAINS. The 50 to 60 not so ... and below 50 needs serious work.

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Please enter your email to receive your score. * This field is required.

example@example.com

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Please note that this is a voluntary test and you need to visit your doctor if your results are below 40. Kindly note that the purpose of this assessment is to help you plan your daily brain habits to avoid memory issues in life. Limitless brain lab or any person does not bear any direct liability for the report. This is a statistically validated brain fitness score and is used as a screening tool for brain health . * This field is required.