Intake form

Name *

Email address *

What is your age?

What is your gender?

Do you have a family history of cognitive decline or alzheimer's dementia?

What symptoms are you currently experiencing?

Please select at least one option.

Memory loss

Difficulty concentrating

Confusion

Language problems

Mood changes

Have you been diagnosed with any cognitive disorders?

If yes, please specify the diagnosis.

What medications are you currently taking?

What lifestyle factors do you consider relevant to your brain health?

Please select at least one option.

Diet

Exercise

Sleep quality

Stress management

Social engagement

How did you hear about us?

Additional questions or comments

Brain Health Initiative