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