2-Minute Brain Optimization Assessment
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Full Name
Email
*
Phone
*
How did you hear about us?
Q1. How would you describe your current brain health?
I feel great
I have a few occasional issues
I struggle more often than I'd like
I don't feel like myself anymore
Q2. How often do you experience the following?
2.1 Brain Fog
Never
Occasionally
Weekly
Daily
2.2 Difficulty concentrating
Never
Occasionally
Weekly
Daily
2.3 Memory issues
Never
Occasionally
Weekly
Daily
2.4 Mental fatigue
Never
Occasionally
Weekly
Daily
2.5 Headaches
Never
Occasionally
Weekly
Daily
2.6 Migraines
Never
Occasionally
Weekly
Daily
2.7 Dizziness
Never
Occasionally
Weekly
Daily
2.8 Poor sleep
Never
Occasionally
Weekly
Daily
2.9 Anxiety
Never
Occasionally
Weekly
Daily
2.10 Depression/ Low Mood
Never
Occasionally
Weekly
Daily
2.11 Light sensitivity
Never
Occasionally
Weekly
Daily
2.12 Noise sensitivity
Never
Occasionally
Weekly
Daily
Q3. Have you ever experienced any of the following?
Concussion
Multiple concussions
Long COVID
Stroke
ADHD
PTSD
Military Service
Chronic Migraines
Lyme Disease
Mold Exposure
Autoimmune Disease
Parkinson's Disease
Alzheimer's/ Dementia
None of the above
Q4. Which symptoms affect your daily life the most
Poor Memory
Difficulty Focusing
Brain Fog
Fatigue
Low Motivation
Mood Changes
Anxiety
Headaches
Balance Issues
Slower Thinking
None
Q5. When did these symptoms begin
No Symptoms
Less than 3 months ago
3-12 months ago
1-3 years ago
More than 3 years ago
Q6. What have you already tried?
Medication
Physical Therapy
Chiropractic
Counseling
Supplements
Nutrition Changes
Exercise Program
Hyperbaric Oxygen Therapy
Red Light Therapy
None
Q7. What is your primary goal?
Think more clearly
Improve memory
More energy
Better sleep
Recover from concussion
Recover from stroke
Reduce headaches
Improve athletic performance
Prevent future decline
Other
Q8. How much do these symptoms affect your quality of life?
Q9. How motivated are you to improve your brain health?
Q10. If we could help improve one thing over the next six months, what would it be? (Remember names, Less brain fog, Better focus, More energy, Fewer headaches)