Please read this list of behaviors and rate yourself on each behavior listed. Use the following scale and place the appropriate number next to the item.

  • 0 = never
  • 1 = rarely
  • 2 = occasionally
  • 3 = frequently
  • 4 = very frequently
Inability to give close attention to details or avoid careless mistakes

Trouble sustaining attention in routine situations (homework, chores, paperwork, etc.)

Trouble listening

Inability to finish things, poor follow-through

Poor organization of time or space

Distractibility

Poor planning skills

Difficulty expressing feelings and emotions

Difficulty expressing empathy for others

Excessive daydreaming

Boredom

Conflict seeking

Difficulty awaiting turn

Impulsivity (saying or doing things without thinking first)

Frequent traffic violations

Please read this list of behaviors and rate yourself on each behavior listed. Use the following scale and place the appropriate number next to the item.

  • 0 = never
  • 1 = rarely
  • 2 = occasionally
  • 3 = frequently
  • 4 = very frequently
Excessive or senseless worrying

Being upset when things do not go your way

Being upset when things are out of place

Tendency to be oppositional or argumentative

Tendency to have repetitive negative thoughts

Tendency toward compulsive behaviors

Intense dislike of change

Tendency to hold grudges

Trouble shifting attention from subject to subject

Trouble shifting behavior from task to task

Difficulties seeing options in situations

Tendency to hold on to own opinion and not listen to others

Being very upset unless things are done a certain way

Perception by others that you worry too much

Tendency to say no without first thinking about question

Unhealthy perfectionism

Please read this list of behaviors and rate yourself on each behavior listed. Use the following scale and place the appropriate number next to the item.

  • 0 = never
  • 1 = rarely
  • 2 = occasionally
  • 3 = frequently
  • 4 = very frequently
Feelings of nervousness or anxiety

Symptoms of heightened muscle tension (headaches, sore muscles, hand tremor)

Feeling keyed up or on edge

Quick to startle

Tendency to freeze in anxiety-provoking situations

Conflict avoidance

Lacking confidence

Sensitive to criticism

Biting fingernails or picking at skin

Always watching for bad things to happen

Excessive motivation

Tics

Poor handwriting

Please read this list of behaviors and rate yourself on each behavior listed. Use the following scale and place the appropriate number next to the item.

  • 0 = never
  • 1 = rarely
  • 2 = occasionally
  • 3 = frequently
  • 4 = very frequently
Feelings of sadness

Moodiness

Low energy

Excessive guilt

Crying spells

Lowered interest in things usually considered fun

Low self-esteeme

Decreased Interest in sex

Negative sensitivity to smells/odors

Forgetfulness

Poor Concentration

Feelings often or easily hurt

Feeling overwhelmed by the tasks of daily living

Sensitive to criticism

Lacking confidence in own abilities

BRIGHT MINDS Risk Assessment Mark the risks that apply to you. If you don't know if you have a risk factor, such as ones requiring certain lab tests, leave it unchecked. The number in parentheses is the relative increase in risk for brain problems or accelerated aging compared to those without that risk factor. Here’s how it translates: 1.3 = 30% increased risk; 1.5 = 50% increased risk; 2 = double the risk, 3 = triple the risk, and so on.

Blood Flow Risk Factors

History of Stroke (5)

History of cardiovascular disease, including coronary artery disease, heart attacks, heart failure, heart arrhythmias (2)

Pre-hypertension or hypertension in midlife (2)

Limited exercise, less than twice a week (2)

Retirement/Aging

Age: 65 to 84 (2)

Age: 85 and older (38)

Watching too much television (more than two hours a day) (2)

In a job that does not require new learning or retired without new learning endeavors (2)

Loneliness or social isolation (2)

Inflammation

Periodontal (gum) disease (2)

Presence of inflammation in the body, such as high homocysteine or C-reactive protein (2)

Low omega-3 fatty acids (2)

Genetics and Family History

One family member with Alzheimer’s or dementia (3.5)

More than one family member with Alzheimer’s or dementia (7.5)

One apolipoprotein E4 gene (2.5)

Two E4 genes (10)

Head Trauma

A single head injury with loss of consciousness (2)

Several head injuries without a loss of consciousness (2)

Loss of one’s sense of smell (2)

Toxic

Smoking cigarettes for 10 years or longer (currently or in past) (2.3)

Alcohol dependence or drug dependence (currently or in past) (4.4)

History of radiation for head and neck cancers (3)

Chemotherapy for breast cancer (1.5)

Chemotherapy for colorectal cancer (1.25)

Chronic exposure to heavy metals, such as lead, cadmium, mercury, arsenic or aluminum (1.5)

Chronic mold exposure (1.5)

Kidney dysfunction (2)

Mental Health Issues

PTSD (4)

bipolar disorder (2)

schizophrenia (2)

depression (3.5)

chronic stress (2)

Immunity/Infection Issues

multiple sclerosis (1.5)

rheumatoid arthritis (3)

systemic lupus erythematosus (2)

Crohn’s disease (1.5)

severe psoriasis (3)

Adult asthma (1.3)

Chronic Lyme disease or other infectious diseases not fully treated (2)

Neurohormone Deficiencies

Low in thyroid (2)

estrogen (females only) (2)

Testosterone (2)

Hysterectomy without estrogen replacement (2)

History of prostate cancer with testosterone-lowering treatment (2)

Diabesity

Pre-diabetes or diabetes (3)

Fasting blood sugar over 100mg/dl (2)

Being overweight or obese in middle age (3)

Sleep Issues

Chronic insomnia (2.3)

Sleep apnea (2)

By submitting this form you acknowledge that you agree to and accept the site Terms of Use and Privacy Policy

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

#Mastermind2023

Year of Change

Don’t Miss Out! Join us in 2023 and affect real change in your life. Learn and master scientifically proven techniques to improve the power and health of your brain in our group Mastermind: Program Your Life virtual class.

Receive the latest news

Subscribe To Our Weekly Newsletter

Stay in the know with weekly tips and information.