*Please type your first and last name

*Please type your e-mail address

*Is this the first time you are evaluating yourself? Yes No

Please read each of the following statements and rate your ability in these areas according to the scale provided.

*I can maintain proper attention even when distractions are present. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I pay attention to details. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can get the gist of a story when I hear or read it. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I finish the tasks that I start. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can remember addresses, phone numbers, dates, names and other basic facts. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can remember experiences, names and events that happened last week. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*Once I learn to do a task, I remember how to do it days or weeks later. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*When I read a book or see a movie, I can remember the details of the story and the order things happened. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can remember the details of verbal or written instructions and carry out the instructions correctly. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*When someone describes the rules of a game, I instantly understand what to do without need of additional repetition or explanation. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can handle tasks that are complex and require significant mental effort without getting frustrated. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I plan ahead and use forethought. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*Before acting on a situation, I take the potential consequences of my action into consideration. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I am good at finding solutions to problems. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can predict the outcome of situations and stories. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I use imagination and creativity. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can easily follow a map. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I learn new things quickly. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I can visualize how a room would look if the furniture were moved into different places. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

*I make few careless errors. Choose only one of the following Almost Always Often Sometimes Seldom Almost Never

Things that I would like to be able to do better than I currently do (please list up to 5 activities).

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Please review the activities you listed when you first evaluated yourself as things you would like to be better able to do. Have you noticed any changes in your abilities to do those things? (If you cannot find your list, please contact us at 877-BRAIN-10 and we would be happy to e-mail you the list.)

*What was the total duration (in weeks) that you used BrainWare to this point? Please only input numeric values. Only numbers may be entered in this field

*What was the frequency (average times per week) that you used BrainWare ? Please only input numeric values. Only numbers may be entered in this field

*What was the length of each session (average minutes) that you used BrainWare ? Please only input numeric values. Only numbers may be entered in this field

Have you noticed any changes in your mental processing since starting to use BrainWare Safari? if you feel like sharing, please include a brief explanation.

We would love to hear any comments about your experience with BrainWare Safari.

*Would you be willing to share your story for our "Adult Users' Stories" page? Yes No

Thank you. We will be in touch!

Before you submit your responses to the rating scale, we recommend that you print the screen for your records.