Brain Health-Self Assessment (BHSA)

Brain Health Self Assessment - 20 items
(to be completed based on your life over the last year)

       DATE:           TIME (24hr): 


INSTRUCTIONS: Below is a list activities and risks people that affect brain health.
Please read each one carefully, then click the circle to indicate how much you have in the past year.


  How much physical exercise do you get? (20 points):

0 pts

1 pt

2 pts

3 pts

4 pts
  1.  How many hours per week do you spend doing aerobic exercise?
0-1
1-2
2-3
3-4
4+
  2.  How many hours per week do you spend doing strengthening exercises?
0-1
1-2
2-3
3-4
4+
  3.  In your exercise, how many hours per week are strenuous?
0-1
1-2
2-3
3-4
4+
  4.  How many minutes of your exercise is focused on developing balance?
0-30
30-60
60-90
90-120
120+
  5.  Do you enjoy your exercise program?
No
A little bit
Moderately
Quite a bit
extremely



  How careful are you with your diet and nutrition? (20 points)

0 pts

1 pt

2 pts

3 pts

4 pts

5 pts
  6.  How many servings of fruits and vegetables do you eat each day?
 0
 1
 2
 3
 4
 5
  7.  How many servings of omega-3-fatty acids (fatty fish, avocados, olive oil, grass fed meats, etc.) do you have on average per day?
 0
 1
 2
 3
 4
 5
  8.  How many servings of complete proteins (animal sources, beans, quinoa, etc) do you have on average per day?
 0
 1
 2
 3
 4
 5
  9.  How many cups of water do you drink on average per day?
 0
 1
 2
 3
 4
 5



  How much mental exercise do you get? (15 points)

0 pts

1 pt

2 pts

3 pts

4 pts

5 pts
 10.  How often do you learn and/or do something new?
Never
Rarely
Occasionally
Sometimes
Usually
Daily
 11. How often do you mentally engage in subjects that interest you? (hrs/wk)
0 - 5
6 - 10
11 - 15
16 - 20
20 - 25
25+
 12. How often do you engage in mentally challenging activities? (hrs/wk)
0 - 5
6 - 10
10 - 15
15 - 20
20 - 25
25+



  How often do you socialize with individuals/groups? (10 points)

0 pts

1 pt

2 pts

3 pts

4 pts

5 pts
 13. How many times do you socialize with individuals and/or groups in a week?
 0
 1
 2
 3
 4
 5
 14. How many different individuals or groups do you socialize with in a week?
 0
 1
 2
 3
 4
 5



  How well do you care for your mental health? (15 points)

0 pts
never

1 pt
rarely

2 pts
occasionally

3 pts
sometimes

4 pts
usually

5 pts
always
 15. How rested do you feel in the morning after waking up?
  

  

  

  

  

  

 16. How often do you feel content, not depressed, full of energy?
  

  

  

  

  

  

 17. How often do you check your cognitive function including memory to see if it is OK and not declining.
  

  

  

  

  

  




  Do you work to decrease the risks to your brain health? (20 points)

0 pts
never

1 pt
rarely

2 pts
occasionally

3 pts
sometimes

4 pts
usually

5 pts
always
 18. Do you visit your clinician on a regular basis (at least 1x/yr if over 50 years of age), or as needed and follow recommendations for controlling blood pressure and cholesterol?
  

  

  

  

  

  

 19. Do you wear a seat belt when in a car and wear a helmet when you are riding a bicycle or participating in any activity where you might hit your head?
  

  

  

  

  

  

 20. Do you maintain an environment safe from falls and blows to the head?
  

  

  

  

  

  

 21. Do you fall asleep and stay asleep without medication?
  

  

  

  

  

  



    

TEXT FOR YOUR RECORDS

BHSA  maximum score = 100

0    -  19      poor
20  -  39      low
40  -  59      fair
60  -  69      good
over  70      excellent

Brain Health Self Assessment developed in 2016 by Steve Cain, Curtis Ashford, and Wes Ashford

Site constructed and maintained by:  J. Wesson Ashford, M.D., Ph.D.
    Electronic mail address:   washford@medafile.com
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Dr. Ashford is licensed to practice medicine in the states of California and Kentucky.
          Last update:  09/8/2021