New Patient Questionnaire

Help us understand your brain health goals so we can personalise your session. Takes about 5–8 minutes.

Step 1 of 5
Step 1 of 5
About You
A few details so we know who we're speaking with.
Personal Details
Step 2 of 5
Current Brain Functioning
Rate how you're experiencing each area right now, on average over the past month. 1 = very poor, 10 = excellent.
Rate Your Current Functioning
Ability to remember names, appointments, what you were doing
Ability to stay on task, resist distraction
How clear and sharp your thinking feels
Stability of mood, ability to manage emotions
How rested and restored you feel after sleep
Sustained mental energy throughout the day
How well you're coping with life pressures
How quickly your brain processes and responds to information
Current Symptoms
Step 3 of 5
Your Goals
What would you like to achieve from your Brain Lab sessions?
Priority Areas
In Your Own Words
What does success look like to you after working with us?
An optional add-on that analyses your genetic profile for insights into memory, mood, cognitive resilience, and neurological risk factors. Add-on cost: $175.00 + HST
Step 4 of 5
Health Background
This helps us understand your brain health in context. All information is confidential.
Medical History
Lifestyle
Hormonal changes can significantly impact brain function, mood, memory, and sleep. This helps us contextualise your results.
Previous Brain Health Interventions
Step 5 of 5
A Few Final Questions
Almost done — just a little more to help us prepare for your session.
About Your Session
Expectations & Readiness
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Thank you — we've got your answers!

Your questionnaire has been received by the 2nd Act Health & Testing Services team. We'll review your responses before your Brain Lab session so we can make the most of your time together.

See you soon!