Neuroprotection Assessment Form
Please complete this form to help assess your neurological health and protective factors.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Are you currently experiencing any neurological symptoms? (e.g., memory loss, headaches, numbness)
*
Memory loss
Headaches
Numbness or tingling
Difficulty concentrating
No symptoms
Other
Do you have a history of any of the following conditions?
*
Stroke or TIA
Traumatic brain injury
Neurodegenerative disease (e.g., Alzheimer's, Parkinson's)
Epilepsy or seizures
None of the above
Other
Please indicate any risk factors that apply to you:
Family history of neurological disorders
High blood pressure
Diabetes
Smoking
Excessive alcohol consumption
None of the above
List any current medications or supplements you are taking (optional)
Which of the following protective lifestyle habits do you practice regularly?
Regular physical exercise
Balanced diet rich in fruits and vegetables
Stress management techniques (e.g., meditation, yoga)
Adequate sleep (7-8 hours/night)
Social engagement
Other
Submit Assessment
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