Adrenal Questionnaire

Today's Date:______________

Instructions:  Please enter the appropriate response number to each statement in the columns below.

0= Never/Rarely

1= Occasionally/Slightly

2= Moderate in Intensity or Frequency

3= Intense/Severe or Frequent

 

I have not felt well since_________ when___________________________

                                    (date)                            (describe event, if any)

 

Predisposing Factors

   Past   Now

1____   ____   I have experienced long periods of stress that have affected my well being.

2____   ____  I have had one or more severely stressful events that have affected my well being.

3____   ____  I have driven myself to exhaustion.

4____   ____  I overwork with little play or relaxation for extended periods.

5____   ____  I have had extended, severe or recurring respiratory infections.

6____   ____  I have taken long term or intense steroid therapy (corticosteroids).

7____   ____  I tend to gain weight, especially around the middle (spare tire).

8____   ____  I have a history of alcoholism &/or drug abuse.

9____   ____  I have environmental sensitivities.

10____   ____  I have diabetes (type II, adult onset, NIDDM).

11____   ____  I suffer from post traumatic distress syndrome.

12____   ____  I suffer from anorexia.*

13____   ____  I have one or more other chronic illnesses or diseases.

  ____   ____  Total

Key Signs & Symptoms

     Past   Now

1____   ____  My ability to handle stress and pressure has decreased.

2____   ____  I am less productive at work.

3____   ____  I seem to have decreased in cognitive ability.  I don't think as clearly as I used to.

4____   ____  My thinking is confused when hurried or under pressure.

5____   ____  I tend to avoid emotional situations.

6____   ____  I tend to shake or am nervous when under pressure.

7____   ____  I suffer from nervous stomach indigestion when tense.

8____   ____  I have many unexplained fears/anxieties.

9____   ____  My sex drive is noticeably less than it used to be.

10____   ____  I get lightheaded or dizzy when rising rapidly from a sitting or lying position.

11____   ____  I have feelings of graying out or blacking out.

12____   ____  I am chronically fatigued; a tiredness that is not usually relieved by sleep.*

13____   ____  I feel unwell much of the time.

14____   ____  I notice that my ankles are sometimes swollen - the swelling is worse in the evening.

15____   ____  I usually need to lie down or rest after sessions of psychological or emotional  pressure/stress.   

16____   ____  My muscles sometimes fell weaker than they should.

17____   ____  My hands and legs get restless - experience meaningless body movements.

18____   ____  I have become allergic or have increased frequency/severity of allergic reactions.

19____   ____  When I scratch my skin, a white line remains for a minute or more.

20____   ____  Small irregular dark brown spots have appeared on my forehead, face, neck and shoulders.

21____   ____  I sometimes feel weak all over.*

22____   ____  I have unexplained and frequent headaches.

23____   ____  I am frequently cold.

24____   ____  I have decreased tolerance for cold.*

25____   ____  I have low blood pressure.

26____   ____  I often become hungry, confused, shaky or somewhat paralyzed under stress.

27____   ____  I have lost weight without reason while feeling very tired and listless.

28____   ____  I have feelings of hopelessness or despair.

29____   ____  I have decreased tolerance.  People irritate me more.

30____   ____  The lymph nodes in my neck are frequently swollen (I get swollen glands on my neck).

31____   ____  I have times of nausea and vomiting for no apparent reason.*

  ____   ____  Total

Energy Patterns

     Past   Now

1____   ____  I often have to force myself in order to keep going.  Everything seems like a chore.

2____   ____  I am easily fatigued.

3____   ____  I have difficulty getting up in the morning. (don't really want up until about 10am).

4____   ____  I suddenly run out of energy.

5____   ____  I usually feel much better and fully awake after the noon meal.

6____   ____  I often have an afternoon low between 3:00-5:00pm.

7____   ____  I get low energy, moody, or foggy if I do not eat regularly.

8____   ____  I usually feel my best after 6pm.

9____   ____  I am often tired at 9:00-10:00pm, but resist going to bed.

10____   ____  I like to sleep late in the morning.

11____   ____  My best, most refreshing sleep often comes between 7:00-9:00am.

12____   ____  I often do my best work late at night (early in the morning).

13____   ____  If I don't go to bed by 11:00pm, I get a second burst of energy, often lasting until 1 - 2am.

  ____   ____  Total

Frequently Observed Events

     Past   Now

1____   ____  I get coughs/colds that stay around for several weeks.

2____   ____  I have frequent or recurring bronchitis, pneumonia or other respiratory infections.

3____   ____  I get asthma, colds and other respiratory involvements two or more times per year.

4____   ____  I frequently get rashes, dermatitis or other skin conditions.

5____   ____  I have rheumatoid arthritis.

6____   ____  I have allergies to several things in the environment.

7____   ____  I have multiple chemical sensitivities.

8____   ____  I have chronic fatigue syndrome.

9____   ____  I get pain in the muscles of my upper back and lover neck for no apparent reason.

10____   ____  I get pain in the muscles on the sides of my neck.

11____   ____  I have insomnia or difficulty sleeping.

12____   ____  I have fibromyalgia.

13____   ____  I suffer from asthma.

14____   ____  I suffer from hay fever.

15____   ____  I suffer from nervous breakdowns.

16____   ____  My allergies are becoming worse (more severe, frequent or diverse).

17____   ____  The fat pads on the palms fo my hands and/or tips of my fingers are often red.

18____   ____  I bruise more easily than I used to.

19____   ____  I have a tenderness in my back near my spine at the bottom of my rib cage when pressed.

20____   ____  I have swelling under my eyes upon rising that goes away after I have been up for a couple of hours.

The next 2 questions are for women only

     Past   Now

21____   ____  I have increasing symptoms of PMS, such as cramps, bloating, moodiness, irritability,

emotional instability, headaches, tiredness, and/or intolerance before my period (only some of these need be present).

22____   ____  My periods are generally heavy but they often stop, or almost stop, on the fourth day,

             only to start up profusely on the 5th or 6th day.

  ____   ____  Total

Food Patterns

     Past   Now

1____   ____  I need coffee or some other stimulant to get going in the morning.

2____   ____  I often crave food high in fat and feel better with high fat foods.

3____   ____  I use high fat foods to drive myself.

4____   ____  I often use high fat foods and caffeine containing drinks (coffee, colas, chocolate) to drive myself.

5____   ____  I often crave salt and/or foods high in salt.  I like salty foods.

6____   ____  I feel worse if I heat high potassium foods (like bananas, figs, raw potatoes), especially if I eat them in the morning.

7____   ____  I crave high protein foods (meats, cheeses).

8____   ____  I crave sweet foods (pies, cakes, pastries, doughnuts, dried fruits, cadies or desserts).

9____   ____  I feel worse if I miss or skip a meal.

  ____   ____  Total

Aggravating Factors

     Past   Now

1____   ____  I have constant stress in my life or work.

2____   ____  My dietary habits tend to be sporadic and unplanned.

3____   ____  My relationships at work and/or home are unhappy.

4____   ____  I do not exercise regularly.

5____   ____  I eat lots of fruit.

6____   ____  My life contains insufficient enjoyable activities.

7____   ____  I have little control over how I spend my time.

8____   ____  I restrict my salt intake.

9____   ____  I have gum and/or tooth infections or abscesses.

10____   ____  I have meals at irregular times.

  ____   ____  Total

Relieving Factors

     Past   Now

1____   ____  I feel better almost right away once a stressful situation is resolved.

2____   ____  Regular meals decrease the severity of my symptoms.

3____   ____  I often feel better after spending a night out with friends.

4____   ____  I often feel better if I lie down.

5____   ____  Other relieving factors _______________________________________

                       __________________________________________________________

  ____   ____  Total