Pre-consultation: Cognitive Performance

First name *

Last name *

Email *

Phone *

Date of birth *

Select all that apply: *

Memory loss

Concentration difficulties

Brain fog

Word-finding difficulty

Processing speed

Decision making

Mental stamina / Fatigue

Multitasking difficulty

How long have you noticed these concerns? *

Onset was: *

Sudden

Gradual

How much is this affecting your work or daily life? *

Minimal impact

Moderate impact

Significant impact

Severe - affecting ability to function

How would you rate your sleep quality? *

Poor sleep significantly impacts cognitive function

Excellent

Good

Fair

Poor

Average hours of sleep per night: *

Do you experience insomnia, sleep disruption, or daytime sleepiness? *

No

Yes - insomnia

Yes - frequent night waking

Yes - daytime sleepiness

Current stress level: *

Low

Moderate

High

Very high / Burnout

Work hours per week:

Do you have adequate time for stress management and recovery? *

Yes

Partially

No

Hours per day on screens (work + leisure)?

How often do you take digital breaks? *

Regular breaks (20-20-20 rule)

Occasional breaks

Rarely

Exercise frequency per week: *

Physical activity improves cognitive function and blood flow to the brain

None

1-2 sessions

3-4 sessions

5+ sessions

Type of exercise (select all that apply):

Cardio

Strength training

Yoga / Pilates

Meditation / Mindfulness

Walking

Other

Omega-3 intake (fatty fish, supplements)?

Regular (3+ times per week)

Occasional

None

B vitamin intake (leafy greens, eggs, whole grains)?

Good

Moderate

Poor

Hydration: glasses of water per day?

Alcohol consumption per week (units):

1 unit = 10ml pure alcohol. Excess affects cognition and memory

Cannabis use:

Cannabis can impair concentration and short-term memory

Never

Occasional

Regular

Daily

Recreational drugs:

Never used

Past use

Occasional use

Regular use

Have you experienced any of these? (select all that apply)

Head injury or concussion

ADHD

Depression

Anxiety

Thyroid disorder

Menopause / Perimenopause

Long COVID

Sleep apnoea

Stroke or TIA

Parkinson's or other neurological condition

Are you currently taking any medications? *

No

Yes

VO2 max (from Apple Watch, Garmin, etc):

Resting heart rate (bpm):

Average HRV (heart rate variability):

Average sleep score (if tracked):

Any family history of cognitive decline, dementia, or Alzheimer's?

No

Yes - parent

Yes - sibling

Yes - other relative

Not sure

Select all that apply: *

Investigation (bloods, scans, testing)

Cognitive optimisation strategies

Supplement advice

Medication review

Cognitive training recommendations

Lifestyle changes

Anything else about your cognition you'd like to discuss?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

What concerns you most about your cognition?

Select all that apply: -

How long have you noticed these concerns? -

Onset was: -

How much is this affecting your work or daily life? -

Sleep & Rest

How would you rate your sleep quality? -

Average hours of sleep per night: -

Do you experience insomnia, sleep disruption, or daytime sleepiness? -

Stress & Burnout

Current stress level: -

Work hours per week: -

Do you have adequate time for stress management and recovery? -

Screen Time & Digital Overload

Hours per day on screens (work + leisure)? -

How often do you take digital breaks? -

Physical Activity

Exercise frequency per week: -

Type of exercise (select all that apply): -

Nutrition & Cognitive Support

Omega-3 intake (fatty fish, supplements)? -

B vitamin intake (leafy greens, eggs, whole grains)? -

Hydration: glasses of water per day? -

Substance Use

Alcohol consumption per week (units): -

Cannabis use: -

Recreational drugs: -

Medical History

Have you experienced any of these? (select all that apply) -

Medications

Are you currently taking any medications? -

Wearable Data (if available)

VO2 max (from Apple Watch, Garmin, etc): -

Resting heart rate (bpm): -

Average HRV (heart rate variability): -

Average sleep score (if tracked): -

Family History

Any family history of cognitive decline, dementia, or Alzheimer's? -

What would help you most?

Select all that apply: -

Anything else about your cognition you'd like to discuss? -

Upload any recent cognitive test results or medical reports

Optional: PDF or image files only, max 10MB

Click to upload files

Anything else for your doctor?