Cognitive Optimization Medical Activation Intake
Provide your details and recent health context for activation data collection only.
Unique ID
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Cognitive Goal
*
Which of the following cognitive areas are you concerned about? (Select all that apply)
*
Focus
Memory
Word recall
Brain fog
Processing speed
Mental stamina
Other
When did your cognitive concerns begin (onset)?
How do these concerns impact your daily functioning?
On average, how many hours do you sleep per night?
How would you rate your sleep quality?
Excellent
Good
Fair
Poor
Do you snore?
Yes
No
Unsure
Do you experience daytime sleepiness?
Never
Rarely
Sometimes
Often
How would you rate your stress or burnout level?
Low
Moderate
High
Severe
How would you describe your mood and anxiety?
Do you experience any symptoms after meals (e.g., fatigue, brain fog, digestive issues)? Please describe.
How much water do you typically drink per day (in ounces or liters)?
How much protein do you consume daily (grams or servings)?
How often do you consume alcohol?
Please Select
Never
Occasionally
1-2 times/week
3-5 times/week
Daily
How much caffeine do you consume daily (coffee, tea, energy drinks)?
Do you use any substances (nicotine, cannabis, recreational drugs)?
Nicotine
Cannabis
Other recreational drugs
None
How often do you exercise?
Please Select
Never
1-2 times/week
3-5 times/week
Daily
Have you ever had a head injury or concussion?
Yes
No
Unsure
Do you have any neurological diagnoses or history (e.g., seizures, MS, Parkinson's, stroke)? Please describe.
Please list any current medications (name and dose):
Do you use any of the following?
Stimulants
Antidepressants
Sleep aids
Nootropics
Supplements
None
Do you use a wearable device to track health or sleep?
Yes
No
How ready do you feel to make changes to support your cognitive wellness?
Not ready
Somewhat ready
Ready
Very ready
What type of support do you prefer?
One-on-one coaching
Group support
Self-guided resources
Other
Medication allergies or adverse reactions
Pregnancy status
Not applicable
Pregnant
Not pregnant
Prefer not to say
Would you like your provider contacted urgently about any concerns?
Yes
No
Unsure
Signature
*
Submit
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