Brain Nutrition Program Form

Please complete the following form to enroll in the Brain Nutrition Program.

"*" indicates required fields

01 • Personal Information

Name*
MM slash DD slash YYYY

02 • Health Background

03 • Lifestyle & Activities

Do you enjoy competitive activities?*
On a scale of 1 to 5, with 5 being the most ambitious, how ambitious are you?*
On a scale of 1 to 5, with 5 being the most disciplined, how disciplined are you?*
Physician fees are out of pocket, and we do not participate in any insurance plans including medicare or medicaid. Is this workable for you?*
There are usually specialty tests whose fees are directly payable to the laboratory, which are not covered by insurance, is this acceptable?*
Are you free of substance use such as alcohol or recreational drugs?*
Do you have someone who can keep you organized living with you?*
Do you have an emotionally supportive other living with you?*

04 • Additional Information