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
