On a Scale of 1 to 10, How would you rate your Mental Health? (10 = Best)
*
1-4
4-6
6-8
8-10
Over the past 2 weeks, how often have forgotten small details?
*
Not at All
Several Days
More Days than Not
Nearly Every Day
Over the past 2 weeks, how often have you been unable to Focus?
*
Not at All
Several Days
More Days than Not
Nearly Every Day
Do You Take Vitamins or Supplements?
Yes
No
What's your Monthly Budget for Vitamins/Supplements?
<$60
$60-$100
$100-$150
>$150
Are you Feeling Stressed or Anxious?
*
Yes
No
How's your Sleep?
*
Great
Needs Improvement
Would you consider trying supplementation to help with this?
*
Yes
No
Which area of Brain Health are you most interested in improving?
*
Sleep Quality
Stress & Anxiety
Focus & Memory
All of the Above
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