Brain Fitness Score

1

Date* This field is required.

Date

2

Name* This field is required.

First Name

Last Name

4

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

6

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

7

I’ve been full of energy (1- not at all, 5- everyday)* This field is required.

8

I’ve been easily distracted ( 1-5)* This field is required.

9

I’ve been feeling stressed or anxious ( 1-5)* This field is required.

10

I’ve been struggling with brain fog ( 1-5)* This field is required.

11

I’ve been struggling to remember things (1-5)* This field is required.

12

Research shows your brain needs some very specific nutrients to function at its full potential. The focus here is on whether or not you get the nutrients, rather than the source you get them from, as this varies with diet and lifestyle choices. Hence punch in the questions related to your diest in the next section.

13

Take an omega 3 supplement OR Eat 2 portions of oily fish weekly?* This field is required.

YESNO

14

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

YESNO

15

Now for some idea about your brain-boosting habits. How many days last week did you.. do an activity? Answer in the number of days of the week you did the activity as presented in the next sections.

16

Practice meditation or mindfulness for at least 10 minutes per day?.( 0- 7 days)* This field is required.

17

Pet active for 30 minutes or more, e.g. walking, yoga, workouts etc. (0-7 days)* This field is required.

18

Drink more than 2 L of water ( 0-7)

19

Now for the brain challenges! How many days last week did you?

20

Drink two or more alcoholic drinks? ( 0-7 days)* This field is required.

21

Smoked tobacco? ( 0-7 days)* This field is required.

22

Take prescribed medication, or other drugs that affect the brain? ( 0-7)* This field is required.

23

Recommended dietary habits include:

4-5 servings of fruit and vegetables per day;
2 servings of lean protein per day
3 or more servings of whole grains per day
Less than 1,500 mg of sodium per day
Less than 36 oz of sugar-sweet beverages (soda, juice, etc.) per week

24

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

25

How would you rate your sleep ( 1 is terrible, 5 is Excellent)* This field is required.

26

How connected did you feel to friends and family ( 1-5)* This field is required.

27

How healthy would you rate your food choices? (1-5)* This field is required.

28

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

29

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

YESNO

30

I have been diagnosed with Heart disease* This field is required.

YESNO

31

I have been diagnosed with high Cholesterol.* This field is required.

YESNO

32

I have been diagnosed with Diabetes(High sugar)* This field is required.

YESNO

33

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

YESNO

34

My concussion history* This field is required.Did you have any head traumas in the past?

No concussion

Concussion with no loss of consciousness

Concussion withloss of consciousness

35

I have concerns about memory loss* This field is required.

Extremely concerned

Moderately concerned

Somewhat concerned

Slightly concerned

Not concerned at all

36

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

Excellent

Very Good

Good

Fair

Poor

37

Phone Number* This field is required.We can send your report on the what's app if you prefer & we can send the personalized regimen for you for your brain health too for free.

Please enter a valid phone number.

39

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

40

Please enter your email to receive your score, as well as free personalized brain health tips to help you improve your scores* This field is required.

example@example.com