Adrenal Fatigue: The 21st Century Stress Syndrome: Adrenal Questionnaire

Adrenal Fatigue Questionnaire

From Adrenal Fatigue: The 21st Century Stress Syndrome
by Dr. James L. Wilson

Instructions: Please enter the appropriate response number to each statement in the columns below. Use the values in the rating scale below. Once you have answered all of the questions, scroll to the bottom of the page and click the "Calculate" button. Your score and assesment will be tabulated and displayed.

Rating Scale

0	Never / rarely
1	Occasionally / Slightly
2	Moderate in intensity or frequency
3	Intense / severe or frequent

Past	Now	Predisposing Factors
		I have experienced long periods of stress that have affected my well being.
		I have had one or more severely stressful events that have affected my well being.
		I have driven myself to exhaustion.
		I overwork with little play or relaxation for extended periods.
		I have had extended, severe or recurring respiratory infections.
		I have taken long term or intense steroid therapy (corticosteroids).
		I tend to gain weight, especially around the middle (spare tire).
		I have a history of alcoholism and/or drug abuse.
		I have environmental sensitivities.
		I have diabetes (Type II, adult onset, NIDDM).
		I suffer from post-traumatic stress syndrome.
		* I suffer from anorexia.
		I have one or more other chronic illnesses or diseases.

Past	Now	Key Signs and Symptoms
		My ability to handle stress or pressure has decreased.
		I am less productive at work.
		I seem to have decreased in cognitive ability. I don't think as clearly as I used to.
		My thinking is confused when hurried or under pressure.
		I tend to avoid emotional situations.
		I tend to shake or am nervous when under pressure.
		I suffer from nervous stomach indigestion when tense.
		I have many unexplained fears/anxieties.
		My sex drive is noticeably less than it used to be.
		I get lightheaded or dizzy when rising rapidly from a sitting or lying position.
		I have feelings of graying or blacking out.
		* I am chronically fatigued; a tiredness that is not usually relieved by sleep.
		I feel unwell much of the time.
		I notice that my ankles are swollen -- the swelling is worse in the evening.
		I usually need to lie down or rest after sessions of psychological or emotional pressure/stress.
		My muscles sometimes feel weaker than they should.
		My hands and legs get restless -- experience meaningless body movements.
		I have become allergic or have increased frequency/severity of allergic reactions.
		When I scratch my skin a white line remains for a minute or more.
		Small, irregular dark brown spots have appeared on my forehead, face, neck and shoulders.
		* I sometimes feel weak all over.
		I have unexplained and frequent headaches.
		I am frequently cold.
		* I have a decreased tolerance for cold.
		* I have low blood pressure.
		I often become hungry, confused, shaky or somewhat paralyzed under stress.
		I have lost weight without reason while feeling very tired and listless.
		I have feelings of hopelessness and despair.
		I have decreased tolerance. People irritate me more.
		The lymph nodes in my neck are frequently swollen (I get swollen glands on my neck).
		* I have times of nausea and vomiting for no apparent reason.

Past	Now	Energy Patterns
		I often have to force myself in order to keep going. Everything seems like a chore.
		I am easily fatigued.
		I have difficulty getting up in the morning (don't really wake up until about 10:00 AM).
		I suddenly run out of energy.
		I usually feel much better and fully awake after the noon meal.
		I often have an afternoon low between 3:00-5:00 PM.
		I get low on energy, moody or foggy if I do not eat regularly.
		I usually feel my best after 6:00 PM.
		I am often tired at 9:00-10:00 pm, but resist going to bed.
		I like to sleep late in the morning.
		My best, most refreshing sleep often comes between 7:00-9:00 AM.
		I often do my best work late at night (early in the morning).
		If I don't go to bed by 11:00 PM, I get a second burst of energy around 11:00 PM, often lasting until 1:00-2:00 AM.

Past	Now	Frequently Observed Events
		I get coughs/colds that stay around for several weeks.
		I have frequent, recurring bronchitis, pneumonia or other respiratory infections.
		I get asthma, colds, and other respiratory involvements two or more times per year.
		I frequently get rashes, dermatitis, or other skin conditions.
		I have rheumatoid arthritis.
		I have allergies to several things in the environment.
		I have multiple chemical sensitivities.
		I have chronic fatigue syndrome.
		I get pain in the muscles of my upper back and lower neck for no apparent reason.
		I get pain in the muscles in the side of my neck.
		I have insomnia or difficulty sleeping.
		I have fibromyalgia.
		I suffer from asthma.
		I suffer from hay fever.
		I suffer from nervous breakdowns.
		My allergies are becoming worse (more severe, frequent or diverse).
		The fat pads on palms of my hands and/or tips of my fingers are often red.
		I bruise more easily than I used to.
		I have tenderness in my back near my spine at the bottom of my ribcage when pressed.
		I have swelling under my eyes upon rising that goes away after I have been up for a couple of hours.
		(Women Only) I have increasing symptoms of premenstrual syndrome (PMS) such as cramps, bloating, moodiness, irritability, emotional instability, headaches, tiredness, and/or intolerance before my period (only some of these need be present).
		(Women Only) My periods are generally heavy but they often stop, or almost stop, on the fourth day, only to start up profusely on the 5ht or 6th day.

Past	Now	Food Patterns
		I need coffee or some other stimulant to get going in the morning.
		I often crave food high in fat and feel better with high fat foods.
		I use high fat foods to drive myself.
		I often use high fat foods and caffeine containing drinks (coffee, colas, chocolate) to drive myself.
		I often crave salt and/or foods high in salt. I like salty foods.
		I feel worse if I eat high potassium foods (like bananas, figs, raw potatoes), especially if I eat them in the morning.
		I crave high protein foods (meats, cheeses).
		I crave sweet foods (pies, cakes, pastries, doughnuts, dried fruits, candies or desserts.)
		I feel worse if I miss or skip a meal.

Past	Now	Aggravating Patterns
		I have constant stress in my life or work.
		My dietary habits tend to be sporadic and unplanned.
		My relationships at work and/or home are unhappy.
		I do not exercise regularly.
		I eat lots of fruit.
		My life contains insufficient enjoyable activities.
		I have little control over how I spend my time.
		I restrict my salt intake.
		I have gum and/or tooth infections or abscesses.
		I have meals at irregular times.

Past	Now	Relieving Factors
		I feel better almost right away once a stressful situation is resolved.
		Regular meals decrease the severity of my symptoms.
		I often feel better after spending a night out with friends.
		I often feel better if I lie down.

Return to: Adrenal Fatigue: The 21st Century Stress Syndrome

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