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Scientific Research
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Prescriber Information
Brain Fog Questionnaire
Von Greer
2025-03-26T00:33:17+00:00
Step
1
of
10
10%
1. Do you find yourself having a general sense of forgetfulness, difficulty remembering names, dates, or events?
(Required)
Regularly (daily)
Often (3-4 times a week)
Sometimes (1-2 times a week)
Occasionally (1-2 times a month)
Rarely (less than monthly)
2. Do you have difficulty focusing on tasks or maintaining train of thought during conversations?
(Required)
Regularly (daily)
Often (3-4 times a week)
Sometimes (1-2 times a week)
Occasionally (1-2 times a month)
Rarely (less than monthly)
3. Do you feel like your thinking processes have slowed down and you dread taking on new tasks?
(Required)
Regularly (daily)
Often (3-4 times a week)
Sometimes (1-2 times a week)
Occasionally (1-2 times a month)
Rarely (less than monthly)
4. Do you find it challenging to maintain concentration in activities or conversations for an extended period of time?
(Required)
Regularly (daily)
Often (3-4 times a week)
Sometimes (1-2 times a week)
Occasionally (1-2 times a month)
Rarely (less than monthly)
5. Do you struggle to recall words or have "tip-of-the-tongue" moments where you can't think of the right word?
(Required)
Regularly (daily)
Often (3-4 times a week)
Sometimes (1-2 times a week)
Occasionally (1-2 times a month)
Rarely (less than monthly)
6. Do you find it difficult to juggle multiple tasks or switch between tasks smoothly?
(Required)
Regularly (daily)
Often (3-4 times a week)
Sometimes (1-2 times a week)
Occasionally (1-2 times a month)
Rarely (less than monthly)
7. Are you finding it increasingly difficult to solve complex problems?
(Required)
Regularly (daily)
Often (3-4 times a week)
Sometimes (1-2 times a week)
Occasionally (1-2 times a month)
Rarely (less than monthly)
8. Do you have a history of breast cancer, stroke, or clotting disorder?
(Required)
Yes
No
Prefer not to say
9. What is your age range?
(Required)
Under 35
35 – 44
45 – 54
55 – 64
65+
Prefer not to say
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
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