Brain Fitness Score Template

Date

Name

First NameLast Name

How old are you ?

Gender

BMI (Body Mass Index)

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

I’ve been full of energy (1- not at all, 5- everyday)

I’ve been easily distracted ( 1-5)

I’ve been feeling stressed or anxious ( 1-5)

I’ve been struggling with brain fog ( 1-5)

I’ve been struggling to remember things (1-5)

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.

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.

Practice meditation or mindfulness for at least 10 minutes per day?.( 0- 7 days)

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

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

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

Drink two or more alcoholic drinks? ( 0-7 days)

Smoked tobacco? ( 0-7 days)

Take prescribed medication, or other drugs that affect the brain? ( 0-7)

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

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

How would you rate your sleep ( 1 is terrible, 5 is Excellent)

How connected did you feel to friends and family ( 1-5)

How healthy would you rate your food choices? (1-5)

Caffeine use: coffee, energy drink, etc?

My concussion history

I have concerns about memory loss

Final question- considering all things, would you say your health is?

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Total:

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