Home Brain Health Survey
Brain Health Survey
First Name: *
Last Name: *
Email Address: *
Daytime Phone Number: *
Do you suffer from anxiety or depression or are you on medications for them?? *
Do you have trouble remembering people’s names? *
Do you misplace or lose things frequently? *
Do you have difficulty concentrating? *
Do you have difficulty sleeping or do you wake up in the middle of the night? *
Has sexual desire or performance decreased? *
Does your brain seem like it races or never rests? *
Have you lost your creativity? *
Are you irritable? *
Do you feel you have lost your playful nature? *
Let us know what your particular symptoms are:
Would you like to be contacted for a free consultation to discuss your individual symptoms and potential solutions? *
If Yes, what is the best number to reach you?
If Yes, when is the best time of day to call you?
If Yes, what dates and/or times are best for a consultation?