Are You at Risk for Cognitive Decline or Dementia?Are you over the age of 65?* Yes NoDo either of your parents, grandparents, aunts, or uncles have Alzheimer’s or some other form of dementia?* Yes NoDo either of your parents, grandparents, aunts, or uncles had a stroke or heart attack?* Yes NoIs there a family history of heart or vascular problems?* Yes NoDo you live a relatively sedentary lifestyle with little exercise (Less than 15 minutes a day that requires you to breath harder than normal)?* Yes NoHas a doctor ever told you that you were diabetic, borderline diabetic, or that you have insulin resistance?* Yes NoDo you have high blood pressure?* Yes NoDo you sometimes have difficulty hearing (If in doubt ask your partner)?* Yes NoDo you have thyroid problems or difficulty staying warm?* Yes NoHave you experienced prolonged stress or depression?* Yes NoDo you smoke or have you smoked tobacco products?* Yes NoDo you drink 8 oz of drinks containing alcohol or diet sodas daily?* Yes NoDo you have difficulty sleeping at night?* Yes NoAre you on a statin¨ pain¨ sleep¨ hormone or depression medication?* Yes NoAre you retired without a driving purpose?* Yes NoDo 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 NoPlease 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.Δ
