Are You at Risk for Cognitive Decline or Dementia? Are you over the age of 65?* Yes No Do either of your parents, grandparents, aunts, or uncles have Alzheimer’s or some other form of dementia?* Yes No Do either of your parents, grandparents, aunts, or uncles had a stroke or heart attack?* Yes No Is there a family history of heart or vascular problems?* Yes No Do you live a relatively sedentary lifestyle with little exercise (Less than 15 minutes a day that requires you to breath harder than normal)?* Yes No Has a doctor ever told you that you were diabetic, borderline diabetic, or that you have insulin resistance?* Yes No Do you have high blood pressure?* Yes No Do you sometimes have difficulty hearing (If in doubt ask your partner)?* Yes No Do you have thyroid problems or difficulty staying warm?* Yes No Have you experienced prolonged stress or depression?* Yes No Do you smoke or have you smoked tobacco products?* Yes No Do you drink 8 oz of drinks containing alcohol or diet sodas daily?* Yes No Do you have difficulty sleeping at night?* Yes No Are you on a statin¨ pain¨ sleep¨ hormone or depression medication?* Yes No Are you retired without a driving purpose?* Yes No Do you forget more than you used to or find it hard at times to recall the right words or names of people you know well?* Yes No Please Enter Your Information BelowEntering your information below will calculate your results and allow us to email you more in-depth information.Name* First Last Phone*Email* CommentsThis field is for validation purposes and should be left unchanged.