Do you suffer from anxiety or depression or are you on medications for them?

Do you have trouble remembering people’s names?

Do you misplace or lose things frequently?

Do you have difficulty concentrating?

Do you have difficulty falling asleep or do you wake up in the middle of the night?

Has sexual desire or performance decreased?

Does your brain seem like it races or never rests?

Have you lost your creativity?

Do you feel you have lost your playful nature?

Are you irritable?

Let us know what your particular symptoms are:

Would you like to be contacted for a free consultation to discuss your individual
symptoms and potential solutions?

If Yes, what is the best number to reach you?

If Yes, when is the best time of day to call you?

If Yes, what dates are best for a consultation?
Brain Function Survey
Last Name:
Email Address:
Daytime Phone Number:
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First Name:
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