New Client Form

Welcome to Cognitive Care Management®

Cognitive Care Management is your first step in addressing your current and future cognitive health status and overall wellness. We are the place where individuals can take action and reduce their risk for dementia and other chronic diseases of aging. Take a look and see how we can help you age successfully.

First Name

Last Name

Address

Phone Number

Date of Birth

Gender

Marital Status

Ethnicity
Native AmericanCaucasianHispanic/LatinxAsianMixed RaceBlack/African American

Education
High SchoolAssociatesBachelorsMasters/DoctorateOther

Occupation/Job Title

Please list your health and wellness goals:

Are you concerned about your memory and cognition?

Level of Concern

Very ConcernedConcernedSomewhat ConcernedNot Concerned

Has anything triggered a change in your health or memory status? Please describe.

How motivated are you to make changes to your health and cognition?

Level of Motivation

Very MotivatedMotivatedNot Motivated

Blood type
A+O+B+AB+A-O-B-AB-

Personal Medical History

Irritable Bowel Syndrome