Please complete this 28-question form to the best of your ability to help your Preventing Decline Specialist better understand your needs in preparation for your upcoming Lifestyle Assessment appointment. Selected questions will be scored and will provide a McCance Brain Care Score that will be shared with you during your appointment. There are also questions regarding medication intake and your most recent blood/lipid lab test results, so be sure to have that information available. You can email [email protected] if you have any questions.

First Name

Date of birth

Last Name

Email *

Phone *

Address

Street Address

City

State

Country

Postal code

Emergency Contact

Emergency Contact Phone #

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (435) 334-5515 for assistance. You can reply STOP to unsubscribe at any time.

7) Are you currently taking medication prescribed by a physician?

Yes

If Yes to previous questions, please indicate medication and dosage below.

If you marked yes to any of the preceding medical questions, please explain further and indicate any recommendations your primary medical doctor has made regarding your lifestyle habits.

Health Metrics

8) What is your current weight & height?

Weight (pounds)
Height (inches)

9) My most recent Resting Blood Pressure measured:

Greater than 140/90 with or without treatment

120-139/80-89, with or without treatment

Less than 120/80

10) My most recent Hemoglobin A1c (blood sugar) measured:

Greater than 6.4

Between 5.7 and 6.4

Less than 5.7

11) My most recent Total Cholesterol measured:

190 mg/dL or higher

No treatment required or less than 190 mg/dL

If cardiovascular disease is present, LDL is in accordance to the latest CDC recommendations.

CDC Cholesterol Recommendations

Community & Connection

25) Are you a part of a community (religious, service volunteer, etc.) and connect with others face to face?

Yes

If yes, how many days a week do you connect with others face to face?

26) My social relationships are best described as:

I have few or no close connections other than my spouse or children

I have at least two people, other than my spouse or children, that I feel close with and talk about private matters or call upon for help

27) My life purpose is best described as:

I often struggle to find value or purpose in my life

I generally feel that my life has meaning and/or purpose

28) What are your main personal objectives (or what you want to achieve) by completing the Preventing Decline Lifestyle Assessment and working with a health provider?

Waiver of Release:

I have read and completed this form and understand that there are inherent risks associated with any health recommendations or physical activity and recognize it is my responsibility to provide accurate and complete health/medical history information. Furthermore, it is my responsibility to monitor my individual health or physical performance during any activity during or outside my coaching sessions. I understand that Preventing Decline and its employed health provider have reviewed my health history form and when appropriate, made recommendations for me to modify my participation in physical activity during my coaching sessions. I understand that it is my responsibility, to choose whether or not to follow these recommendations. In the event of a medical problem, I further recognize that any medical care that may be required is my personal financial responsibility and do not hold the Preventing Decline, LLC liable.

Today's Date

Signature

Clear

Thank you for completing the Preventing Decline Lifestyle Assessment.

If you haven't already scheduled an appointment with our provider to review your Brain Care Score results, please be on the lookout for an email with a link to schedule one online at a time convenient for you.

We look forward to helping you slow the progression of age and live your best life!