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Quiz V2
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Gender
*
Male
Female
Prefer Not to Say
How old are you?
*
18-24
25-34
35-44
45-54
55-64
65-74
Over 75
Describe the quality of your sleep
*
I typically sleep through the night, waking up no more than once per night.
I wake up about 2-3 times per night and may experience difficulty falling back to sleep
I wake up more than 3 times per night and may experience difficulty falling back to sleep
Do you rely on caffeine throughout the day for energy?
*
Never
Rarely
Sometimes
Often
Always
Do you often have mental chatter about worries and to-do lists?
*
Never
Rarely
Sometimes
Often
Always
How often do you experience brain fog?
*
Never
Rarely
Sometimes
Often
Always
Have you struggled to keep your mood at normal levels?
*
Never
Rarely
Sometimes
Often
Always
Do you have trouble focusing?
*
Never
Rarely
Sometimes
Often
Always
Do you often lose items like keys or wallets?
*
Never
Rarely
Sometimes
Often
Always
Do you struggle finishing things you start?
*
Never
Rarely
Sometimes
Often
Always
Have you ever experienced any significant head trauma in the past?
*
Yes
No
How often do you eat processed or fast foods (minimal vegetables, high carbs, high fat)?
*
Never
Rarely
Sometimes
Often
Always
Do you exercise 3 or more times a week for at least 30 minutes?
*
Yes
No
First_Name
*
Email
*
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