Please rate each question on a scale of 0 to 4. Then add your score using the key below.

0=Never, 1=Rarely, 2=Occasionally,
3=Frequently, 4=Very Freq., N/A

1. My diet is poor and tends to be haphazard.
2. I do not exercise.
3. I put myself at risk for brain injuries by doing such things as not wearing my seat belt, drinking and driving, engaging in high risk sports, and so on.
4. I live under daily or chronic stress, in my home or work life.
5. My thoughts tend to be negative, worried, or angery.
6. I have problems getting at least 6-7 hours of sleep a night.
7. I smoke or am exposed to secondhand smoke.
8. I drink or consume more than two normal-sized (8-ounce) cups of coffee, tea, or dark sodas a day.
9. I use aspartame (found in soft drinks/colas) and/or MSG
10. I am around environmental toxins, such as paint fumes, hair or nail salon fumes, or pesticides.
11. I spend more than one hour a day watching TV.
12. I spend more than one hour a day playing computer or video games.
13. Outside of work time, I spend more than one hour a day on the computer.
14. I have more than three normal-sized drinks of alcohol (8-ounces of beer or wine or 1 once of hard liquor) a week.

KEY:

0-6 Great brain habits

7-12 Really good; work to be better

13-20 Fair; you are prematurely aging your brain

> 20 Poor; time to be very concerned


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