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Clarify page purpose if necessary.
Thank you for your interest in improving your brain health.
Complete the survey below to receive your estimated current brain health and what you can do to improve.
Download Participant Information Form
Brain Health Survey
Step
1
of
11
9%
General Information
Name
First
Last
Email
Enter Email
Confirm Email
What is your gender?
Male
Female
Prefer not to say
Select your date of birth
MM slash DD slash YYYY
What country were you born in?
Australia
Other (please specify)
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Born in other country
*
What is your postcode?
Please enter a number less than or equal to
9999
.
Medical Conditions
Has your doctor ever told you that you have...
A heart or blood vessel condition?
Including heart attack, angina (chest pain), heart failure, stroke, or TIA's
Yes
No
I don't know
Chronic kidney disease?
Yes
No
I don't know
Diabetes?
Yes
No
I don't know
Cholesterol levels that are too high?
Yes
No
I don't know
High blood pressure?
Yes
No
I don't know
Hearing loss?
Yes
No
I don't know
What is your Body Mass Index (BMI)?
Your BMI is easy to find. Simply
enter your height and weight here
and then select your BMI from the list below.
Select your BMI range
Less than 18.5
18.5 – 24.5
25.0 – 30.0
Greater than 30.0
Lifestyle Factors
Do you smoke?
Yes
No
What is your daily average alcohol consumption?
I don't drink alcohol
Up to and including 1 glass a day
More than 1 glass a day
Do you generally consider yourself as an active person?
This is defined as someone who regularly performs exercise in which you start to sweat lightly.
Yes
A little
No
Do you use olive oil as a main culinary fat?
Yes
No
On average, how many hours sleep do you normally get?
Hours per night
1
2
3
4
5
6
7
8
8+
Diet and Food Quantities
How much olive oil do you consume in a given day?
Including oil used for frying, salads, out of house meals, etc.
Tablespoons per day
0
1
2
3
4
5
6
7
8
9
10
10+
How many vegetable servings do you consume per day?
Respond in servings (1 serving = 200g)
Servings per day
0
1
2
3
4
5
6
7
8
9
10
10+
How many fruit servings (include natural fruit juices) do you consume per day?
Respond in servings (1 serving = 75g)
Servings per day
0
1
2
3
4
5
6
7
8
9
10
10+
How many servings of red meat, hamburger or meat products do you consume per day?
Respond in servings (1 serving = 100g-150g)
Servings per day
0
1
2
3
4
5
6
7
8
9
10
10+
How many servings of butter, margarine, or cream do you consume per day?
Respond in servings (1 serving = 12g)
Servings per day
0
1
2
3
4
5
6
7
8
9
10
10+
How many sweet or carbonated beverages do you drink per day?
Per day
0
1
2
3
4
5
6
7
8
9
10
10+
How many servings of legumes (e.g. lentils, chickpeas) do you consume per week?
Respond in servings (1 serving = 150g)
Servings per week
0
1
2
3
4
5
6
7
8
9
10
10+
How many servings of fish or shellfish do you consume per week?
Respond in servings (1 serving = 100-150g of fish)
Servings per week
0
1
2
3
4
5
6
7
8
9
10
10+
How many times per week do you consume commercial sweets or pastries (not homemade) such as cakes, cookies, biscuits or custard?
Times per week
0
1
2
3
4
5
6
7
8
9
10
10+
How many servings of nuts (including peanuts) do you consume per week?
Respond in servings (1 serving = 30g)
Servings per week
0
1
2
3
4
5
6
7
8
9
10
10+
Do you prefer to consume chicken, turkey or rabbit meat instead of veal, pork, hamburger, or sausage?
Yes
No
How many times per week do you consume vegetables, pasta, rice or other dishes seasoned with sofrito?
Sofrito is a type of sauce made with tomato and onion, leek or garlic simmered with olive oil.
Times per week
0
1
2
3
4
5
6
7
8
9
10
10+
Cognition
Education and work history
How many years of education do you have?
Including postgraduate studies and any specialisation
Years
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
30+
How many years of vocational training do you have?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
How many years of working activity in low-skilled manual work do you have?
Includes farm work, gardener, housemaid, caregiver, waiter, driver, mechanic, plumber, call center operator, babysitter, etc.
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
How many years of working skilled manual work do you have?
Craftsman, cook, store clerk, tailor, representative, serviceman/servicewoman, hairdresser, clerical worker, nurse, etc.
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
How many years of working in non-manual work do you have?
Business owner, white-collar employee, sales agent, priest or monk/nun, real estate agent, nursery school teacher, musician, etc.
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
How many years of working in a professional occupation do you have?
Managing director of a small company, lawyer, qualified freelance professional, contractor, doctor, teacher, engineer, etc.
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
How many years of working in a highly responsible or intellectual occupation do you have?
Managing director of a big company, senior manager, judge, university professor, surgeon, politician, etc.
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Your weekly activities
On a weekly basis, how often do you...
Read magazines and newspapers?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Engage in domestic chores?
For example, cooking, washing, grocery shopping, ironing, etc.
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Drive?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Participate in leisure activities?
For example, sports, hunting, dancing, chess, coin collecting, etc.
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Use new technologies?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Monthly activities
On a monthly basis, how often do you...
Participate in social activities?
For example, political parties, recreational clubs, associations, etc.
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Go to the cinema or theatre?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Garden, or do DIY, small-scale hobbies?
For example, knitting, etc.
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Look after grandchildren, nieces, nephews or elderly parents?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Do voluntary work?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Participate in artistic activities?
For example, music, singing, performance, painting, writing, etc.
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Annual activities
On a yearly basis, how often do you...
Go to an exhibition, concert, or conference?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Travel (lasting several days)?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Read books?
None
Once
Twice
Three or more
How many years have you been doing this?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Do you participate in activities with children?
Yes
No
Please indicate how many children
*
How many children?
1
2
3
4
5
6
7
8
9
10
10+
How often do you look after pets?
Never
Sometimes
About half the time
Often
Always
How many years have you been looking after pets?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
How often do you manage your own finances?
Never
Sometimes
About half the time
Often
Always
How many years have you been looking after your finances?
Years
0
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
65+
Mental Health
Over the past two weeks, how often have you been bothered by any of the following problems:
Little interest or pleasure in doing things?
Not at all
Several days
More than half
Nearly everyday
Feeling down, depressed or hopeless?
Not at all
Several days
More than half
Nearly everyday
Trouble falling asleep, staying asleep or sleeping too much?
Not at all
Several days
More than half
Nearly everyday
Feeling tired or having little energy?
Not at all
Several days
More than half
Nearly everyday
Poor appetite or overeating?
Not at all
Several days
More than half
Nearly everyday
Feeling bad about yourself, that you are a failure or that you have let yourself or your family down?
Not at all
Several days
More than half
Nearly everyday
Trouble concentrating on things, such as reading the newspaper or watching television?
Not at all
Several days
More than half
Nearly everyday
Moving or speaking so slowly that other people have noticed, or, being so fidgety or restless that you have been moving around more than usual?
Not at all
Several days
More than half
Nearly everyday
Thoughts that you would be better off dead or hurting yourself in some way?
Not at all
Several days
More than half
Nearly everyday
Social Activity - Relatives
The last few questions are asking about your social networks.
Please select the response that best reflects your experience
over the last 4 weeks
.
How many relatives did you see or hear from?
None
1
2
3-4
5-8
9+
How many relatives did you feel you could talk to about private matters?
None
1
2
3-4
5-8
9+
How many relatives did you feel close to such that you could call on them for help?
None
1
2
3-4
5-8
9+
Social Activity - Friends
The last few questions are asking about your social networks.
Please select the response that best reflects your experience
over the last 4 weeks
.
How many friends did you see or hear from?
None
1
2
3-4
5-8
9+
How many friends did you feel you could talk to about private matters?
None
1
2
3-4
5-8
9+
How many friends did you feel close to such that you could call on them for help?
None
1
2
3-4
5-8
9+
