Brain Fitness Score Template

A short self-assessment that combines sleep, stress, activity, and memory habits into an overall brain health score.

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Date*

Name*

Nombre

Apellido

How old are you?*

18-29 30-44 45-59 60+

Gender*

Male Female Prefer not to say

BMI (Body Mass Index)*

Underweight Normal Overweight Obese

About how you've been feeling this past week

Healthy habits (past 7 days)

Indicate how many of the past 7 days each habit applied

Habits to watch

Quality of life

Rating scale: 1 = poor, 5 = excellent

Caffeine use: coffee, energy drinks, etc.*

None 1-2 cups a day 3-4 cups a day 5+ cups a day

My concussion history*

None One concussion Two or more concussions Not sure

I have concerns about memory loss*

Yes No Sometimes

Final question: considering everything, would you say your health is?*

Excellent Good Fair Poor

Phone Number*

Enter your email to receive your score along with free, personalized tips to improve your brain health*

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