Revitalize Your Brain
Strategy Session Application Form
Name
First Name
Last Name
E-mail
Phone Number
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Area Code
Phone Number
Date
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Month
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Day
Year
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Have you been diagnosed with Mild Cognitive Impairment or early stage Alzheimer's Disease? If yes, when were you diagnosed?
Are you on any medications? If yes, please list.
Has your spouse/partner noticed a change in your memory or ability to carry out day to day tasks? Have your friends or co-workers noticed a difference?
Do any of the scenarios below apply to you? If yes, please check box:
Difficulty recalling names
Problems with recognizing faces of people you have met before
Decreased focus/attention span
Misplacing keys and other items frequently
Being in the middle of a sentence and forgetting what you are going to say
Difficulty learning new concepts or tasks
Takes longer to get projects done
Tasks that used to be easy are now challenging
Struggling to keep up at work
Getting lost while walking or driving
Feeling easily frustrated
Others have noticed a difference in your personality
Your quality of life has been affected
What are your top three health challenges?
What have you done in the past to address these health concerns?
What are your top three health goals?
Are you willing to make diet and lifestyle changes?
Are you willing to take nutritional supplements?
On a scale of 1 to 10 (with 1 being hardly committed and 10 begin fully committed), how committed are you to taking the next step toward healing and feeling better?
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