Brain Assessment Form

Assess Your Brain Health

PATIENT DETAILS

Name

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Last

Date of Birth

Sex

Cell Phone Number

Address

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Address Line 2

City

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Your Assessment Form

Please select the option that best answers each question.

Section A

	Disagree	Neutral	Agree	Strongly Agree
Is your memory noticeably declining?	DisagreeIs your memory noticeably declining? Disagree	NeutralIs your memory noticeably declining? Neutral	AgreeIs your memory noticeably declining? Agree	Strongly AgreeIs your memory noticeably declining? Strongly Agree
Are you having a hard time remembering names and phone numbers?	DisagreeAre you having a hard time remembering names and phone numbers? Disagree	NeutralAre you having a hard time remembering names and phone numbers? Neutral	AgreeAre you having a hard time remembering names and phone numbers? Agree	Strongly AgreeAre you having a hard time remembering names and phone numbers? Strongly Agree
Is your ability to focus noticeably declining?	DisagreeIs your ability to focus noticeably declining? Disagree	NeutralIs your ability to focus noticeably declining? Neutral	AgreeIs your ability to focus noticeably declining? Agree	Strongly AgreeIs your ability to focus noticeably declining? Strongly Agree
Has it become harder for you to learn things?	DisagreeHas it become harder for you to learn things? Disagree	NeutralHas it become harder for you to learn things? Neutral	AgreeHas it become harder for you to learn things? Agree	Strongly AgreeHas it become harder for you to learn things? Strongly Agree
Do you have a hard time remembering your appointments?	DisagreeDo you have a hard time remembering your appointments? Disagree	NeutralDo you have a hard time remembering your appointments? Neutral	AgreeDo you have a hard time remembering your appointments? Agree	Strongly AgreeDo you have a hard time remembering your appointments? Strongly Agree
Is your temperament getting worse in general?	DisagreeIs your temperament getting worse in general? Disagree	NeutralIs your temperament getting worse in general? Neutral	AgreeIs your temperament getting worse in general? Agree	Strongly AgreeIs your temperament getting worse in general? Strongly Agree
Are you losing your attention span endurance?	DisagreeAre you losing your attention span endurance? Disagree	NeutralAre you losing your attention span endurance? Neutral	AgreeAre you losing your attention span endurance? Agree	Strongly AgreeAre you losing your attention span endurance? Strongly Agree

Section B

	Never	Rarely	Sometimes	Often
Do you feel overly stressed?	NeverDo you feel overly stressed? Never	RarelyDo you feel overly stressed? Rarely	SometimesDo you feel overly stressed? Sometimes	OftenDo you feel overly stressed? Often
How often do you feel that you have something that must be done?	NeverHow often do you feel that you have something that must be done? Never	RarelyHow often do you feel that you have something that must be done? Rarely	SometimesHow often do you feel that you have something that must be done? Sometimes	OftenHow often do you feel that you have something that must be done? Often
Do you feel you never have time for yourself?	NeverDo you feel you never have time for yourself? Never	RarelyDo you feel you never have time for yourself? Rarely	SometimesDo you feel you never have time for yourself? Sometimes	OftenDo you feel you never have time for yourself? Often
How often do you feel you are not getting enough sleep or rest?	NeverHow often do you feel you are not getting enough sleep or rest? Never	RarelyHow often do you feel you are not getting enough sleep or rest? Rarely	SometimesHow often do you feel you are not getting enough sleep or rest? Sometimes	OftenHow often do you feel you are not getting enough sleep or rest? Often
Do you find it difficult to get regular exercise?	NeverDo you find it difficult to get regular exercise? Never	RarelyDo you find it difficult to get regular exercise? Rarely	SometimesDo you find it difficult to get regular exercise? Sometimes	OftenDo you find it difficult to get regular exercise? Often
Do you feel uncared for by the people in your life?	NeverDo you feel uncared for by the people in your life? Never	RarelyDo you feel uncared for by the people in your life? Rarely	SometimesDo you feel uncared for by the people in your life? Sometimes	OftenDo you feel uncared for by the people in your life? Often
Do you feel you are not accomplishing your life’s purpose?	NeverDo you feel you are not accomplishing your life’s purpose? Never	RarelyDo you feel you are not accomplishing your life’s purpose? Rarely	SometimesDo you feel you are not accomplishing your life’s purpose? Sometimes	OftenDo you feel you are not accomplishing your life’s purpose? Often
Is sharing your problems with someone difficult for you?	NeverIs sharing your problems with someone difficult for you? Never	RarelyIs sharing your problems with someone difficult for you? Rarely	SometimesIs sharing your problems with someone difficult for you? Sometimes	OftenIs sharing your problems with someone difficult for you? Often

Section C

	Never	Rarely	Sometimes	Often
Do you get fatigued after meals?	NeverDo you get fatigued after meals? Never	RarelyDo you get fatigued after meals? Rarely	SometimesDo you get fatigued after meals? Sometimes	OftenDo you get fatigued after meals? Often
Do you crave sugar and sweets after meals?	NeverDo you crave sugar and sweets after meals? Never	RarelyDo you crave sugar and sweets after meals? Rarely	SometimesDo you crave sugar and sweets after meals? Sometimes	OftenDo you crave sugar and sweets after meals? Often
Do you feel you need stimulants such as coffee after meals?	NeverDo you feel you need stimulants such as coffee after meals? Never	RarelyDo you feel you need stimulants such as coffee after meals? Rarely	SometimesDo you feel you need stimulants such as coffee after meals? Sometimes	OftenDo you feel you need stimulants such as coffee after meals? Often
Do you have difficulty losing weight?	NeverDo you have difficulty losing weight? Never	RarelyDo you have difficulty losing weight? Rarely	SometimesDo you have difficulty losing weight? Sometimes	OftenDo you have difficulty losing weight? Often
How much larger is your waist girth compared to your hip girth?	NeverHow much larger is your waist girth compared to your hip girth? Never	RarelyHow much larger is your waist girth compared to your hip girth? Rarely	SometimesHow much larger is your waist girth compared to your hip girth? Sometimes	OftenHow much larger is your waist girth compared to your hip girth? Often
How often do you urinate?	NeverHow often do you urinate? Never	RarelyHow often do you urinate? Rarely	SometimesHow often do you urinate? Sometimes	OftenHow often do you urinate? Often
Have your thirst and appetite been increased?	NeverHave your thirst and appetite been increased? Never	RarelyHave your thirst and appetite been increased? Rarely	SometimesHave your thirst and appetite been increased? Sometimes	OftenHave your thirst and appetite been increased? Often
Do you have weight gain when under stress?	NeverDo you have weight gain when under stress? Never	RarelyDo you have weight gain when under stress? Rarely	SometimesDo you have weight gain when under stress? Sometimes	OftenDo you have weight gain when under stress? Often
Do you have difficulty falling asleep?	NeverDo you have difficulty falling asleep? Never	RarelyDo you have difficulty falling asleep? Rarely	SometimesDo you have difficulty falling asleep? Sometimes	OftenDo you have difficulty falling asleep? Often

Section D

Section E

	Never	Rarely	Sometimes	Often
How often do you have feelings of hopelessness?	NeverHow often do you have feelings of hopelessness? Never	RarelyHow often do you have feelings of hopelessness? Rarely	SometimesHow often do you have feelings of hopelessness? Sometimes	OftenHow often do you have feelings of hopelessness? Often
How often do you have self-destructive thoughts?	NeverHow often do you have self-destructive thoughts? Never	RarelyHow often do you have self-destructive thoughts? Rarely	SometimesHow often do you have self-destructive thoughts? Sometimes	OftenHow often do you have self-destructive thoughts? Often
How often do you have an inability to handle stress?	NeverHow often do you have an inability to handle stress? Never	RarelyHow often do you have an inability to handle stress? Rarely	SometimesHow often do you have an inability to handle stress? Sometimes	OftenHow often do you have an inability to handle stress? Often
How often do you feel you are not rested even after long hours of sleep?	NeverHow often do you feel you are not rested even after long hours of sleep? Never	RarelyHow often do you feel you are not rested even after long hours of sleep? Rarely	SometimesHow often do you feel you are not rested even after long hours of sleep? Sometimes	OftenHow often do you feel you are not rested even after long hours of sleep? Often
How often do you prefer to isolate yourself from others?	NeverHow often do you prefer to isolate yourself from others? Never	RarelyHow often do you prefer to isolate yourself from others? Rarely	SometimesHow often do you prefer to isolate yourself from others? Sometimes	OftenHow often do you prefer to isolate yourself from others? Often
How often do you have unexplained lack of concern for family and friends?	NeverHow often do you have unexplained lack of concern for family and friends? Never	RarelyHow often do you have unexplained lack of concern for family and friends? Rarely	SometimesHow often do you have unexplained lack of concern for family and friends? Sometimes	OftenHow often do you have unexplained lack of concern for family and friends? Often
How easily are you distracted from your tasks?	NeverHow easily are you distracted from your tasks? Never	RarelyHow easily are you distracted from your tasks? Rarely	SometimesHow easily are you distracted from your tasks? Sometimes	OftenHow easily are you distracted from your tasks? Often
How often do you have an inability to finish tasks?	NeverHow often do you have an inability to finish tasks? Never	RarelyHow often do you have an inability to finish tasks? Rarely	SometimesHow often do you have an inability to finish tasks? Sometimes	OftenHow often do you have an inability to finish tasks? Often
How often do you feel the need to consume caffeine to stay alert?	NeverHow often do you feel the need to consume caffeine to stay alert? Never	RarelyHow often do you feel the need to consume caffeine to stay alert? Rarely	SometimesHow often do you feel the need to consume caffeine to stay alert? Sometimes	OftenHow often do you feel the need to consume caffeine to stay alert? Often
How often do you feel your libido has been decreased?	NeverHow often do you feel your libido has been decreased? Never	RarelyHow often do you feel your libido has been decreased? Rarely	SometimesHow often do you feel your libido has been decreased? Sometimes	OftenHow often do you feel your libido has been decreased? Often
How often do you lose your temper for minor reasons?	NeverHow often do you lose your temper for minor reasons? Never	RarelyHow often do you lose your temper for minor reasons? Rarely	SometimesHow often do you lose your temper for minor reasons? Sometimes	OftenHow often do you lose your temper for minor reasons? Often
How often do you have feelings of worthlessness?	NeverHow often do you have feelings of worthlessness? Never	RarelyHow often do you have feelings of worthlessness? Rarely	SometimesHow often do you have feelings of worthlessness? Sometimes	OftenHow often do you have feelings of worthlessness? Often

Section F

	Never	Rarely	Sometimes	Often
How often do you feel anxious or panic for no reason?	NeverHow often do you feel anxious or panic for no reason? Never	RarelyHow often do you feel anxious or panic for no reason? Rarely	SometimesHow often do you feel anxious or panic for no reason? Sometimes	OftenHow often do you feel anxious or panic for no reason? Often
How often do you have feelings of dread or impending doom?	NeverHow often do you have feelings of dread or impending doom? Never	RarelyHow often do you have feelings of dread or impending doom? Rarely	SometimesHow often do you have feelings of dread or impending doom? Sometimes	OftenHow often do you have feelings of dread or impending doom? Often
How often do you feel knots in your stomach?	NeverHow often do you feel knots in your stomach? Never	RarelyHow often do you feel knots in your stomach? Rarely	SometimesHow often do you feel knots in your stomach? Sometimes	OftenHow often do you feel knots in your stomach? Often
How often do you have feelings of being overwhelmed for no reason?	NeverHow often do you have feelings of being overwhelmed for no reason? Never	RarelyHow often do you have feelings of being overwhelmed for no reason? Rarely	SometimesHow often do you have feelings of being overwhelmed for no reason? Sometimes	OftenHow often do you have feelings of being overwhelmed for no reason? Often
How often do you have feelings of guilt about everyday decisions?	NeverHow often do you have feelings of guilt about everyday decisions? Never	RarelyHow often do you have feelings of guilt about everyday decisions? Rarely	SometimesHow often do you have feelings of guilt about everyday decisions? Sometimes	OftenHow often do you have feelings of guilt about everyday decisions? Often
How often does your mind feel restless?	NeverHow often does your mind feel restless? Never	RarelyHow often does your mind feel restless? Rarely	SometimesHow often does your mind feel restless? Sometimes	OftenHow often does your mind feel restless? Often
How difficult is it to turn your mind off when you want to relax?	NeverHow difficult is it to turn your mind off when you want to relax? Never	RarelyHow difficult is it to turn your mind off when you want to relax? Rarely	SometimesHow difficult is it to turn your mind off when you want to relax? Sometimes	OftenHow difficult is it to turn your mind off when you want to relax? Often
How often do you have disorganized attention?	NeverHow often do you have disorganized attention? Never	RarelyHow often do you have disorganized attention? Rarely	SometimesHow often do you have disorganized attention? Sometimes	OftenHow often do you have disorganized attention? Often
How often do you worry about things you were not worried about before?	NeverHow often do you worry about things you were not worried about before? Never	RarelyHow often do you worry about things you were not worried about before? Rarely	SometimesHow often do you worry about things you were not worried about before? Sometimes	OftenHow often do you worry about things you were not worried about before? Often
How often do you have feelings of inner tension and inner excitability?	NeverHow often do you have feelings of inner tension and inner excitability? Never	RarelyHow often do you have feelings of inner tension and inner excitability? Rarely	SometimesHow often do you have feelings of inner tension and inner excitability? Sometimes	OftenHow often do you have feelings of inner tension and inner excitability? Often

Section G

	Disagree	Neutral	Agree	Strongly Agree
Do you feel your visual memory (shapes & images) is decreased?	DisagreeDo you feel your visual memory (shapes & images) is decreased? Disagree	NeutralDo you feel your visual memory (shapes & images) is decreased? Neutral	AgreeDo you feel your visual memory (shapes & images) is decreased? Agree	Strongly AgreeDo you feel your visual memory (shapes & images) is decreased? Strongly Agree
Do you feel your verbal memory is decreased?	DisagreeDo you feel your verbal memory is decreased? Disagree	NeutralDo you feel your verbal memory is decreased? Neutral	AgreeDo you feel your verbal memory is decreased? Agree	Strongly AgreeDo you feel your verbal memory is decreased? Strongly Agree
Do you have memory lapses?	DisagreeDo you have memory lapses? Disagree	NeutralDo you have memory lapses? Neutral	AgreeDo you have memory lapses? Agree	Strongly AgreeDo you have memory lapses? Strongly Agree
Has your creativity been decreased?	DisagreeHas your creativity been decreased? Disagree	NeutralHas your creativity been decreased? Neutral	AgreeHas your creativity been decreased? Agree	Strongly AgreeHas your creativity been decreased? Strongly Agree
Has your comprehension been diminished?	DisagreeHas your comprehension been diminished? Disagree	NeutralHas your comprehension been diminished? Neutral	AgreeHas your comprehension been diminished? Agree	Strongly AgreeHas your comprehension been diminished? Strongly Agree
Do you have difficulty calculating numbers?	DisagreeDo you have difficulty calculating numbers? Disagree	NeutralDo you have difficulty calculating numbers? Neutral	AgreeDo you have difficulty calculating numbers? Agree	Strongly AgreeDo you have difficulty calculating numbers? Strongly Agree
Do you have difficulty recognizing objects & faces?	DisagreeDo you have difficulty recognizing objects & faces? Disagree	NeutralDo you have difficulty recognizing objects & faces? Neutral	AgreeDo you have difficulty recognizing objects & faces? Agree	Strongly AgreeDo you have difficulty recognizing objects & faces? Strongly Agree
Do you feel like your opinion about yourself has changed?	DisagreeDo you feel like your opinion about yourself has changed? Disagree	NeutralDo you feel like your opinion about yourself has changed? Neutral	AgreeDo you feel like your opinion about yourself has changed? Agree	Strongly AgreeDo you feel like your opinion about yourself has changed? Strongly Agree
Are you experiencing excessive urination?	DisagreeAre you experiencing excessive urination? Disagree	NeutralAre you experiencing excessive urination? Neutral	AgreeAre you experiencing excessive urination? Agree	Strongly AgreeAre you experiencing excessive urination? Strongly Agree
Are you experiencing slower mental response?	DisagreeAre you experiencing slower mental response? Disagree	NeutralAre you experiencing slower mental response? Neutral	AgreeAre you experiencing slower mental response? Agree	Strongly AgreeAre you experiencing slower mental response? Strongly Agree

Medication History

Please check any of the following medications you have or are currently taking.

Agonist Modulator of GABA Receptors (Nonbenzodiazpines)

Ambien
Sonata
Lunesta
Imovane

Cholinesterase Inhibitors (Irreversible)

Echotiophate
Isofl urophate
Organophosphate Insecticides
Organophosphate-containing nerve agents

Dopamine Reuptake Inhibitors

Wellbutrin (Bupropion)

GABA Antagonist Competitive Binder

Flumazenil

Dopamine Receptor Agonists

Mirapex
Sifrol
Requip

- Receptor Enhancers

Selective Serotonin Reuptake Enhancers

Stablon
Coaxil
Tatinol

Other Prescriptions or Drugs Used

Additional Questions or Comments

	Never	Rarely	Sometimes	Often
Are you losing your pleasure in hobbies and interests?	NeverAre you losing your pleasure in hobbies and interests? Never	RarelyAre you losing your pleasure in hobbies and interests? Rarely	SometimesAre you losing your pleasure in hobbies and interests? Sometimes	OftenAre you losing your pleasure in hobbies and interests? Often
How often do you feel overwhelmed with ideas to manage?	NeverHow often do you feel overwhelmed with ideas to manage? Never	RarelyHow often do you feel overwhelmed with ideas to manage? Rarely	SometimesHow often do you feel overwhelmed with ideas to manage? Sometimes	OftenHow often do you feel overwhelmed with ideas to manage? Often
How often do you have feelings of inner rage (anger)?	NeverHow often do you have feelings of inner rage (anger)? Never	RarelyHow often do you have feelings of inner rage (anger)? Rarely	SometimesHow often do you have feelings of inner rage (anger)? Sometimes	OftenHow often do you have feelings of inner rage (anger)? Often
How often do you have feelings of paranoia?	NeverHow often do you have feelings of paranoia? Never	RarelyHow often do you have feelings of paranoia? Rarely	SometimesHow often do you have feelings of paranoia? Sometimes	OftenHow often do you have feelings of paranoia? Often
How often do you feel sad or down for no reason?	NeverHow often do you feel sad or down for no reason? Never	RarelyHow often do you feel sad or down for no reason? Rarely	SometimesHow often do you feel sad or down for no reason? Sometimes	OftenHow often do you feel sad or down for no reason? Often
How often do you feel like you are not enjoying life?	NeverHow often do you feel like you are not enjoying life? Never	RarelyHow often do you feel like you are not enjoying life? Rarely	SometimesHow often do you feel like you are not enjoying life? Sometimes	OftenHow often do you feel like you are not enjoying life? Often
How often do you feel you lack artistic appreciation?	NeverHow often do you feel you lack artistic appreciation? Never	RarelyHow often do you feel you lack artistic appreciation? Rarely	SometimesHow often do you feel you lack artistic appreciation? Sometimes	OftenHow often do you feel you lack artistic appreciation? Often
How often do you feel depressed in overcast weather?	NeverHow often do you feel depressed in overcast weather? Never	RarelyHow often do you feel depressed in overcast weather? Rarely	SometimesHow often do you feel depressed in overcast weather? Sometimes	OftenHow often do you feel depressed in overcast weather? Often
How much are you losing your enthusiasm for your favorite activities?	NeverHow much are you losing your enthusiasm for your favorite activities? Never	RarelyHow much are you losing your enthusiasm for your favorite activities? Rarely	SometimesHow much are you losing your enthusiasm for your favorite activities? Sometimes	OftenHow much are you losing your enthusiasm for your favorite activities? Often
How much are you losing enjoyment for your favorite foods?	NeverHow much are you losing enjoyment for your favorite foods? Never	RarelyHow much are you losing enjoyment for your favorite foods? Rarely	SometimesHow much are you losing enjoyment for your favorite foods? Sometimes	OftenHow much are you losing enjoyment for your favorite foods? Often
How much are you losing your enjoyment of friendships and relationships?	NeverHow much are you losing your enjoyment of friendships and relationships? Never	RarelyHow much are you losing your enjoyment of friendships and relationships? Rarely	SometimesHow much are you losing your enjoyment of friendships and relationships? Sometimes	OftenHow much are you losing your enjoyment of friendships and relationships? Often
How often do you have difficulty falling into deep restful sleep?	NeverHow often do you have difficulty falling into deep restful sleep? Never	RarelyHow often do you have difficulty falling into deep restful sleep? Rarely	SometimesHow often do you have difficulty falling into deep restful sleep? Sometimes	OftenHow often do you have difficulty falling into deep restful sleep? Often
How often do you have feelings of dependency on others?	NeverHow often do you have feelings of dependency on others? Never	RarelyHow often do you have feelings of dependency on others? Rarely	SometimesHow often do you have feelings of dependency on others? Sometimes	OftenHow often do you have feelings of dependency on others? Often
How often do you feel more susceptible to pain?	NeverHow often do you feel more susceptible to pain? Never	RarelyHow often do you feel more susceptible to pain? Rarely	SometimesHow often do you feel more susceptible to pain? Sometimes	OftenHow often do you feel more susceptible to pain? Often
How often do you have feelings of unprovoked anger?	NeverHow often do you have feelings of unprovoked anger? Never	RarelyHow often do you have feelings of unprovoked anger? Rarely	SometimesHow often do you have feelings of unprovoked anger? Sometimes	OftenHow often do you have feelings of unprovoked anger? Often
How much are you losing interest in life?	NeverHow much are you losing interest in life? Never	RarelyHow much are you losing interest in life? Rarely	SometimesHow much are you losing interest in life? Sometimes	OftenHow much are you losing interest in life? Often