1、ADRENAL SYMPTOMS QUESTIONNAIREThe answers to the following set of questions help determine whether the adrenal glands are likely implicated as a factor in a persons health concerns. The questionnaire is not meant to replace laboratory testing, but to be used in conjunction with the standard tests us
2、ed to measure adrenal function. Please rank your symptom according to the categories below and enter a number from 0-4 for each question.0 = Never1 = Occasionally (1 4 times per month)2 = Moderate in severity and occurs moderatelyfrequently (1 4 times per week)3 = Intense in severity and occurs freq
3、uently(more than 4 times per week) KEY SIGNS AND SYMPTOMS 1. _ I get dizzy or see spots when standing up rapidly from a sitting or lying position.2. _ I urinate more frequently than others and may need to get up at night.3. _ I feel as though I might faint or black out.4. _ I have chronic fatigue.5.
4、 _ I have mitral valve prolapse or get heart palpitations.6. _ I often have to force myself on order to keep going.7. _ I have difficulty getting up in the morning.8. _ I have low energy before the noon meal (approx. 11:00 am).9. _ I have low energy in the late afternoon between 3:00 5:00pm.10. _ I
5、usually feel better after 6:00pm. 11. _ I often feel the best late at night because I get a “second wind.” 12. _ I have trouble getting to sleep.13. _ I tend to wake early (3:00 5:00am) and have trouble getting back to sleep.14. _ I have vague feelings of being generally unwell for no apparent reaso
6、n.15. _ I get swelling in the extremities, such as the ankles.16. _ I need to rest after times of mental, physical, or emotional stress.17. _ I feel more tired after exercise, either soon after or the next day.18. _ My muscles feel weak and heavy more than I think they should.19. _ I have chronic te
7、nderness in my back near the bottom of my rib cage. 20. _ I have a weak back and/or weak knees.21. _ I have restless extremities.22. _ I allergic to many things, such as foods, animals and pollens. 23. _ My allergies are getting worse. 24. _ I get bags or dark circles under my eyes, which may be wor
8、se in the morning.25. _ I have multiple chemical sensitivities.26. _ I have asthma or get regular bouts of bronchitis, pneumonia, or other infections.27. _ I have dermatographism ( a white line appears on my skin if I run my fingernail over it and persists for one minute)28. _ I have an area of pale
9、 skin around my lips.29. _ The skin on the palms of my hands and soles of my feet tends to be red/orange.30. _ I tend to have dry skin.31. _ I tend to get headaches and a sore neck and shoulders.32. _ I am sensitive to bright light.33. _ I frequently feel colder than others around me. 34. _ I have d
10、ecreased tolerance for cold.35. _ I have Raynauds syndrome (extremely cold hands/feet).36. _ My temperature tends to be below normal when measured with a thermometer.37. _ My temperature tends to fluctuate through the day.38. _ I have low blood pressure.39. _ I become hungry, confuse, or shaky if I
11、miss a meal.40. _ I crave sugar, sweets, or deserts.41. _ I use stimulants, such as tea or coffee, to get started in the morning. 42. _ I crave food high in fat and feel better with high-fat foods.43. _ I need caffeine (chocolate, tea, coffee, colas) to get me through the day.44. _ I often crave sal
12、t and/or foods high in salt, such as potato chips.45. _ I feel worse if I eat sweets and no protein for breakfast. 46. _ I do not eat regular meals.47. _ I eat fast-foods often. 48. _ I am sensitive to pharmaceutical or nutritional supplements.49. _ I have taken steroid medications for a long term o
13、r at high doses. 50. _ I have symptoms that improve after I eat. 51. _ I tend to be thin and find it difficult to put weight on.52. _ I have feelings of hopelessness and despair or have dealt with depression.53. _ I lack motivation because I do not feel I have energy to get things done.54. _ I have
14、decreased tolerance towards people and tend to get irritated easily. 55. _ I get more than two colds or flus per year.56. _ It takes me a long time to recover from illness.57. _ I get rashes, dermatitis, eczema, psoriasis, or other chronic skin conditions. 58. _ I have an autoimmune disease. 59. _ I
15、 have fibromyalgia. 60. _ I have had mononucleosis or been diagnosed with Epstein Barr virus. 61. _ I do not exercise regularly.62. _ I have a history of large amounts of stress in my life. 63. _ I tend to be a perfectionist.64. _ My health ins negatively affected by stress.65. _ I tend to avoid str
16、essful situations for the sake of my health. 66. _ I am less productive at work than I used to be. 67. _ My ability to focus mentally is generally impaired. 68. _ Stressful situations hinder my ability to focus.69. _ Stress causes me to become overly anxious.70. _ I startle easily.71. _ It can take
17、me days or weeks to recover from a stressful event. 72. _ I tend to get digestive disturbances when tense. 73. _ I tend to get unexplained fears and phobias. 74. _ My sex drive is very low or non-existent. 75. _ My relationships at work and/or home tend to be strained. 76. _ My life contains insuffi
18、cient time for fun and enjoyable activities. 77. _ I have little control over my life and I feel “stuck.” 78. _ I tend to get addicted easily to drugs, alcohol, or foods.79. _ I suffer from post-traumatic distress disorder. 80. _ I have or have had an eating disorder. 81. _ I have gum disease and/or
19、 tooth infections or abscesses. Next two questions for women only: 82. _ I have symptoms of premenstrual syndrome (PMS).83. _ My periods are irregular and/or affected by stress. _ Total ScoreRef. Friedman, ND & Wilson, MDHORMONE BALANCE TESTRead carefully through the list of symptoms in each group a
20、nd put a check mark next to each symptom that you have. (If you check off the same symptom in more than one group, thats fine). HORMONE BALANCE TEST FOR MEN_ Weight loss _ Enlarged breast _ Loss of muscle _ Lower stamina_ Low sex drive _ Softer erections _ Fatigue _ Gallbladder problemsTotal Boxes C
21、hecked _ (Symptom Box # 1)_ Hair loss _ Headaches _ Prostate enlargement _ Breast enlargement_ Irritability _ Weight gain _ Puffiness or bloatingTotal Boxes Checked _ (Symptom Box # 2) HORMONE BALANCE TEST FOR WOMEN_ PMS _ Insomnia _ Early miscarriage _ Painful or lumpy breasts_ Unexplained Weight g
22、ain _ Cyclical headaches _ Anxiety _ Infertility Total Boxes Checked _ (Symptom Box # 1)_ Vaginal dryness _ Night sweats _ Painful intercourse _ Memory Problems_ Bladder infections _ Lethargic depression _ Hot flashes Total Boxes Checked _ (Symptom Box # 2) _ Puffiness and bloating _ Abnormal pap sm
23、ear _ Rapid weight gain_ Breast tenderness _ Mood swings _ Heavy bleeding _ Insomnia _ Anxious depression _ Migraine headaches _ Foggy thinking _ Red flushed face _ Gallbladder problems _ Weepiness Total Boxes Checked _ (Symptom Box # 3) A combination of the symptom boxes #1 and #3Total Boxes Checke
24、d _ (Symptom Box # 4) _ Acne _ Polycystic ovary syndrome _ Excessive hair on face and arms _ Hypoglycemia or unstable blood sugar _ Thinning hair on the head_ Infertility _ Ovarian cysts _ Midcycle pain Total Boxes Checked _ (Symptom Box # 5)_ Debilitating fatigue _ Unstable blood sugar _ Foggy thin
25、king _ Low blood pressure _ Thin and/or dry skin _ Intolerance to exercise _ Brown spots on face Total Boxes Checked _ (Symptom Box # 6) Ref. HYPOCHLORHYDRIA SCREENING QUIZ: LOW STOMACH ACID ASSESSMENTPlease take your time reading each question carefully. Check next to either true or false to answer
26、 the questions: 1. I tend to have weak fingernails (brittle, peeling, ridges).( ) True ( ) False2. I often have bloating, gas, or belching after meals.( ) True ( ) False3. I tend to feel full for quite some time after meals, or feel food sitting in my stomach.( ) True ( ) False4. I usually have bad
27、breath.( ) True ( ) False5. I seem to age prematurely, even though I eat well, exercise, avoid sun exposure, etc. ( ) True ( ) False6. I have a strong appetite.( ) True ( ) False7. I often have constipation and/or diarrhea.( ) True ( ) False8. I have or have had iron deficiency anemia.( ) True ( ) F
28、alse9. My hair is thin, brittle, or weak.( ) True ( ) False10. I dont digest food well. I often feel uncomfortable or unwell after eating.( ) True ( ) False11. My skin tends to be dry and/or weak. ( ) True ( ) False12. I have a history of one or more of the following conditions: acne, eczema, rosacea, psoriasis, vitiligo, autoimmune disease, rheumatoid arthritis, osteoporosis, adrenal fatigue, bacteria overgrowth, candida yeast infection, food allergies.( ) True ( ) False Ref. www.A
