Clone of Clone of Clone of Brain Fitness Score @limitlessbrainlab

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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

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

7

Describe how often do you get distracted. 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.

8

I feel quite anxious and stressed most times for last few weeks or more. ( 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.

9

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.

10

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

11

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

YESNO

12

Do you 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

13

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.

14

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.

15

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.

16

Do you 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.

17

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

18

Do you smoke any kind of tobacco in a day? ( 0-7 days)* This field is required.Smoking can lead to cognitive decline.

19

Do you take any kind of prescription medication for any disease? ( 0-7 days)* This field is required.How many days of the week , you take those tablets/medications?

20

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

21

How would you rate your sleep ( 1 is pretty unrestful & 5 is Excellent)* This field is required.A sound sleep is the foundation of a super brain.

22

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

23

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.

24

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

25

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

YESNO

26

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

YESNO

27

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

YESNO

28

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

YESNO

29

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

YESNO

30

Have you injured your head and had concussion of the brain in the past?* This field is required.Please mention only if there was a concussion(Found on brain imaging)

No concussion

Concussion with no loss of consciousness

Concussion with loss of consciousness

31

Do you have concerns about the memory loss?* This field is required.Memory issues disrupting your daily life?

Extremely concerned

Moderately concerned

Somewhat concerned

Slightly concerned

Not concerned at all

32

Final question- Considering all things, would you say your brain 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.

Country Code

Area Code

Phone Number

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

example@example.com

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This is a voluntary self-assessment tool intended to support your awareness and daily brain health practices. If your score falls below 40, it is strongly recommended that you consult a qualified medical professional. The purpose of this assessment is to guide your lifestyle choices and help prevent future memory-related concerns.* This field is required.

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Total:If you have scored more than 60, hurray. Carry on the good work. Your brain is fit and healthy. If you scored between 50 to 60, you are doing a good job but not a great job. If you have scored below 50, some immediate life style changes are necessary. Let us work on it.