Brain Health Screening Form
This assessment is beneficial if you think you, a parent or a loved one are showing signs of decline in cognitive abilities.
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Email *

Are you doing it yourself? 

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Required
Name *
Contact No *
Age *
Gender *
Occupation *
Education *
Marital Status *
Do you smoke? *
Do you drink? *
Do you have the following- diabetic/HT/Heart diseases?
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Did you have Head injuty/stroke?

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Did you ever seek help for mental illness like depression?
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Do you have hearing difficulties?
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How often do you exercise in a week?

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How often do you feel hopeless?
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Are you able to enjoy things you like to do?

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Do you have difficulty falling asleep?

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Are you eating well?
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Do you tend to worry/get anxious?
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Are you able to motivate yourself to work//participate?
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Are you able to enjoy time with family?
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Do you have difficulty remembering things that have happened recently?
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Do you have difficulty keeping track of things like appointments or birthdays?
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Do you often find it difficult to remember the date or lose track of the time of day?
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Do you feel that you are becoming more forgetful than others of your age group?
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Do you get confused while using familiar routes, e.g, going to the market?
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Are you facing difficulty using familiar appliances at home, e.g., the microwave?
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Do you struggle to find words, e.g., to express yourself or of common objects?
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Do you find it difficult to follow a story, e.g., on TV or when reading a book?
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Do you feel you have to work harder than usual to keep track of what you are doing?
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Do you feel that you are taking more time compared to earlier when making decisions?
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Would you like to get your brain health further checked at our Memory Clinic? *
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