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Description

This questionnaire includes 32 statements describing everyday ‘brain behaviours’ that you may or may not have experienced. It is a subjective assessment enabling you to identify your areas of difficulty and the amount of concern you may experience as a result.

The information obtained from your answers help us to select the best set of exercises for your needs.

  • We will not share your details and e-mail address with any third party.
  • You can choose to delete your profile at any time. The information you have provided will be permanently removed from our system.
  • We will not send you unwanted e-mail.

Instructions

Please respond to all question items as honestly as you can. Be sure to answer every question to ensure you receive a brain train report. There are no right or wrong answers so it is important to answer each question for yourself. If you make a mistake or want to change your answer you can by clicking the mouse on the item and clicking on your new response. It is anticipated that this questionnaire will take you 15 minutes to complete.

To receive an accurate assessment all fields must be answered. To receive a personal Brain Train report please provide valid lifestyle details.

Frequency is the number of times you experience this problem when completing tasks or participating in activities. Concern is the amount of anxiety or worry these problems cause you.

1. What is your first name?
2. What is your surname?
3. What is your e-mail address?
Your report will be sent to this email address. Please ensure it is correct.
4. What is the year of your birth?
5. Are you male or female?
6. I have difficulty thinking through the consequences of a decision.
Frequency
NEVERALWAYS
Concern
NONESEVERE
7. I forget where I put personal items and household objects.
Frequency
NEVERALWAYS
Concern
NONESEVERE
8. I do things without thinking.
Frequency
NEVERALWAYS
Concern
NONESEVERE
9. I don't catch all the information from the radio and television.
Frequency
NEVERALWAYS
Concern
NONESEVERE
10. I forget what I was talking about.
Frequency
NEVERALWAYS
Concern
NONESEVERE
11. I am slow to respond in conversations.
Frequency
NEVERALWAYS
Concern
NONESEVERE
12. I lose my place when completing tasks.
Frequency
NEVERALWAYS
Concern
NONESEVERE
13. I find my writing hard to read.
Frequency
NEVERALWAYS
Concern
NONESEVERE
14. I lose track of what activity I am engaged in. For example, you might go into a room and forget the purpose of why you went there.
Frequency
NEVERALWAYS
Concern
NONESEVERE
15. I find the captions on TV or subtitles on a movie are too fast.
Frequency
NEVERALWAYS
Concern
NONESEVERE