Brain Health Audit
Please enter for your information on each of the questions listed below.
This is for your eyes only. The information will not be shared with anyone else.
Brain health is your most critical asset. Your brain is the organ of learning, loving and behaving. When your brain works right, you work right. When your brain is troubled, you are much more likely to have trouble in your life. Unfortunately, many people do not think about the health of their brains and subsequently the rest of their lives suffer.

This brain health audit will help you assess the health of your brain and brain healthy habits. After seeing over 80,000 brain scans over the last 22 years from patients from 90 different countries Dr. Amen has discovered that having a great brain comes down to 2 strategies: avoiding behaviors that hurt your brain and engaging in regular brain healthy habits. Complete this audit with answers that best match your behavior over the last month. When youíre finished, we will show you simple steps you can take right away to enhance your brainís health and function. Please always feel free to call us with any questions: 888-564-2700.

Please enter your email (*)
Birth Date
Gender:
Height: (*) :
Weight: (*)
Waist size? (measure at belly button, donít guess)
1. Describe your memory?
2. What is your current level of stress?
3. How is your focus and attention span?
4. Describe your level of impulsivity (saying or doing things without thinking it through)?
5. Describe your level of compulsivity (an uncontrollable urge to do something even though you do not want to do it)?
6. Describe your current level of emotional flexibility?
7. How is your mood?
8. Describe your current level of anxiety?
9. Describe your energy level?
10. Do you depend on caffeine or other stimulants to keep your energy up?
11. Describe your temper?
12. How many hours of sleep do you average a night?
13. Do you have trouble getting or staying asleep?
14. Do others say you snore loudly and/or stop breathing when you sleep?
15. Do you have cravings for food, alcohol or drugs?
16. Describe your current level of pain?
17. How often do you exercise?
18. How many normal size drinks of alcoholic beverages do you have in a typical week? A normal size is considered an ounce of hard liquor, 8 ounces of beer or wine.
19. Have you or someone else ever thought you had a problem with alcohol or drugs?
20. Do you use nicotine in any form, such as cigarettes, cigars, chewing tobacco and nicotine gum?
21. Are you exposed to second hand smoke?
22. What is your daily caffeine consumption (caffeine is found in coffee, tea, chocolate, dark sodas and caffeine pills)?
23. Describe your diet?
24. Do you use artificial sweeteners, such as aspartame (Nutrasweet), sucralose (Splenda), or saccharin (Sweet and Low) or monosodium glutamate (MSG)
25. Do you take a multiple vitamin and mineral complex?
26. Do you take a fish oil supplement?
27. What is your Vitamin D level?
28. How is your blood pressure?
29. Do you engage in high risk activities, such as not wearing your seatbelt, high risk sports, motorcycle riding, etc.?
30. Do you spend time around environmental toxins, such as pesticides, paint fumes, hair or nail salon fumes, cleaning products or severe air pollution?
31. How often are you involved in new learning activities or brain training games?
32. Are you in an intimate relationship?
33. What is your fasting blood sugar?
34. Do you have prediabetes or diabetes?
35. Do you have heart disease?
36. Your cholesterol is?
37. Have you ever had a head injury (with or without a loss of consciousness) and subsequent symptoms, such as nausea or vomiting, light sensitivity, dizziness, mood or memory problems? Think about any falls, sports concussions, motor vehicle accidents or fights.
38. Your thoughts tend to be?
39. Do you spend more than one hour a day watching TV or playing video games?
40. Are you taking psychiatric medication for ADHD, anxiety, depression, or other mental health issue?



Your results will be mailed to you in a moment.

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