How old is your parent? *

Under 60

60-70

70-80

80+

Did you notice them having any memory problems? *

🧠 No, memory seems sharp

🤏 Sometimes forgets small things

⚠️ Often forgets tasks or conversations

🚨 Strong and Common Memory Loss

How much physical activity does your parent get? *

🏃 Walks daily or exercises regularly

🚶 Moves around a few times a week

🪑 Mostly sits, minimal movement

🛋️ Avoids physical activity entirely

How well does your parent sleep? *

🛌 Sleeps 7–8 hours consistently, feels rested

😴 Sleep is decent but a bit inconsistent

🥱 Often sleeps too little or too much

⚠️ Poor sleep or clear sleep problems

How would you describe your parent’s diet? *

🥦🥩🥝 Mostly healthy, lots of fresh foods

🍗🌽🥐 A mix of healthy and processed

🍕🥞🥡 Often unhealthy or processed

🍟🍩🍫 Mostly junk food or fast food

Daily, how many hours do they spend watching TV or sitting? *

🟢 📚 Under 1 hour

🟡 🎧 1–3 hours

🟠 📺 3–5 hours

🔴 🛋️ 5 hours+

How socially connected is your parent? *

🤝 Sees or talks to people daily

☎️ Connects with others a few times a week

🕰️ Often spends days without much interaction

🚪 Rarely interacts with anyone

How often do they do brain-engaing activities? *

🧩 Daily or almost daily

📖 A few times per week

🗓️ Occasionally

💤 Rarely or never

How often does your parent drink alcohol? *

Does your parent seem stressed, anxious, or down? *

🌞 Mostly calm and upbeat

🌥️ Occasionally stressed or sad

🌧️ Often seems low or withdrawn

🌪️ Constant stress, anxiety, or depression

First Name *

Email *

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