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About
Conditions We Treat
APEX Approach
Patient Journeys
Learn

Cognitive Decline Survey

Cognitive Decline Survey

Cognitive Decline Survey

Step 1 of 20

5%

Welcome. This survey will highlight the underlying causes of your symptoms. What is your greatest frustration that you are looking for help with?*

Enter the symptoms or conditions you are looking for information or help with?

Are you experiencing or have you experienced an inability to remember people, places, or events?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced confusion?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced difficulty learning or retaining new information?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced trouble finding the right words?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced challenges with attention and focus?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced decreased motivation?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced poor decision making or judgement?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced a disinterest in life or normally pleasurable activities?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced struggles with balance, coordination, or walking?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced a decrease in muscle mass, strength, or weight?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced decreased ability to smell or taste?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced fatigue?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced any changes in your vision or hearing?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced irritability, anger, or hostility?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced tingling in your hands, feet, or face?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced a decrease in physical activity levels?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you experiencing or have you experienced any concerns from loved ones about your mental or physical abilities?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Are you willing to do the work necessary to overcome these challenges?*
- Never/No
- Rarely
- Sometimes
- Often
- Always/Yes

Please enter the following information
Your Name*
Your Email*
Your Phone*
Thank you for taking the first step towards education and healing. We help people find their path back to health every day. Our clinical staff will review your survey and contact with the results. What is your preferred way?*
- Short Call! 🙂
- Email Me! 🙂

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Contact Details

828.708.5274
info@apexbraincenters.com
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600 Julian Ln. STE 650,
Arden, NC 28704

Our approach is one of functional neurology. Through the use of state-of-the-art brain mapping, objective neurological testing, intensive research-based brain training methods, and nutritional intervention, we are able to assess and train the brain to perform at peak condition.

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