1、.Adrenal QuestionnaireTodays Date: _I have not felt well since when _(Date) (Describe event, if any)Enter the appropriate response number to each statement below: 0= Never / Rarely 1= Occasionally / Slightly2= Moderate in Intensity or Frequency 3= Intense / Severe or FrequentPredisposing Factors:Now
2、 PastI have experienced long periods of stress that have affected my well beingI have had one or more severely stressful events that have affected my well beingI have driven myself to exhaustionI overwork with little play or relaxation for extended periodsI have had extended, severe or recurring res
3、piratory infectionsI have taken long term or intense steroid therapy (corticosteroids)I tend to gain weight, especially around the middle (spare tire)I have history of alcoholism and/or drug abuseI have environmental sensitivitiesI have diabetes (type II, adult onset, NIDDM)I suffer from post trauma
4、tic distress syndromeI have one or more other chronic illnesses or diseasesTotal Key Signs and Symptoms:Now PastMy ability to handle stress and pressure has decreasedI am less productive at workI seem to have decreased in cognitive ability. I dont think as clearly as I used toMy thinking is confused
5、 when hurried or under pressureI tend to avoid emotional situationsI tend to shake or am nervous when under pressureI suffer from nervous stomach indigestion when tenseI have many unexplained fears / anxietiesMy sex drive is noticeably less than it used to beI get lightheaded or dizzy when rising ra
6、pidly from a sitting or lying positionI have feelings of graying out or blacking outI am chronically fatigued; a tiredness that is not usually relieved by sleep *I feel unwell most of the timeI notice that my ankles are sometimes swollen - the swelling is worse in the eveningI usually need to lie do
7、wn or rest after sessions of psychological or emotional pressure/ stressMy muscles sometimes feel weaker than they shouldMy hands and legs get restless - experience meaningless body movementsI have become allergic or have increased frequency / severity of allergic reactionsWhen I scratch my skin, a
8、white line remains for a minute or moreSmall irregular dark brown spots have appeared on my forehead, face, neck and .shouldersI sometimes feel weak all over *I have unexplained and frequent headachesI am frequently coldI have decreased tolerance for cold *I have low blood pressure *I often become h
9、ungry, confused, shaky or somewhat paralyzed under stressI have lost weight without reason while feeling very tired and listlessI have feelings of hopelessness or despairI have decreased tolerance. People irritate me moreThe lymph nodes in my neck are frequently swollenI have times of nausea and vom
10、iting for no apparent reason *TotalEnergy Patterns:Now PastI often have to force myself in order to keep going. Everything seems like a choreI am easily fatiguedI have difficulty getting up in the morning (dont really wake up until about 10 AM)I suddenly run out of energyI usually feel much better a
11、nd fully awake after the noon mealI often have an afternoon low between 3-5 PMI get low energy, moody or foggy if I do not eat regularlyI usually feel my best after 6 PMI am often tired at 9-10 PM, but resist going to bedI like to sleep late in the morningMy best, most refreshing sleep often comes b
12、etween 7-9 AMI often do my best work late at night If I dont go to bed by 11 PM, I get a second burst of energy around 11 PM, often lasting until 1-2 AMTotalFrequently Observed Events:Now PastI get coughs / colds that stay around for several weeksI have frequent or recurring bronchitis, pneumonia or
13、 other respiratory infectionsI get asthma, colds and other respiratory involvements two or more times per yearI frequently get rashes, dermatitis, or other skin conditionsI have rheumatoid arthritisI have allergies to several things in the environmentI have multiple chemical sensitivitiesI have chro
14、nic fatigue syndromeI get pain in the muscles of my upper back and lower neck for no apparent reasonI get pain in the muscles on the sides of my neckI have insomnia or difficulty sleepingI have fibromyalgiaI suffer from asthmaI suffer from hay feverI suffer from nervous breakdownsMy allergies are be
15、coming worse (more severe, frequent, or diverse)The fat pads on palms of my hands and / or tips of my fingers are often redI bruise more easily than I used toI have a tenderness in my back near my spine at the bottom of my rib cage when pressed.I have swelling under my eyes upon rising that goes awa
16、y after I have been up a couple of hoursThe next 2 questions are for women onlyI 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 p
17、resent)My periods are generally heavy but they often stop, or almost stop, on the fourth day, only to start up profusely on the fifth or sixth dayTotalFood Patterns:Now PastI need coffee or some other stimulant to get going in the morningI often crave food high in fat and feel better with high fat f
18、oodsI use high fat foods to drive myselfI often use high fat foods and caffeine containing drinks (coffee, colas, chocolate) to drive myselfI often crave salt and / or foods high in salt. I feel worse if I eat high potassium foods (like bananas, figs, raw potatoes), especially if I eat them in the m
19、orningI 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 mealTotalAggravating Factors:Now PastI have constant stress in my life or workMy dietary habits tend to be sporadic and unplanned
20、My relationships at work and / or home are unhappyI do not exercise regularlyI eat lots of fruitMy life contains insufficient enjoyable activitiesI have little control over how I spend my timeI restrict my salt intakeI have gum and / or tooth infections or abscessesI have meals at irregular timesTot
21、alRelieving Factors:Now PastI feel better almost right away once a stressful situation is resolved Regular meals decrease the severity of my symptomsI often feel better after spending a night out with friendsI often feel better if I lie downOther relieving factors are:Total.Scoring and Interpretatio
22、n of the Adrenal QuestionnaireTotal number of questions answered Total Points Name of SectionTotal ResponsesTotal ResponsesName of SectionTotal ResponsesTotal ResponsesNow Past Now PastKey signs and symptoms /31Key signs and symptoms /93Energy Patterns/13Energy Patterns/39Frequently Observed Events/20 for men/22 for womenFrequently Observed Events/60 for men/66 for womenFood Patterns/9Food Patterns/27Aggravating Factors/10Aggravating Factors/30Relieving Factors/4Relieving Factors/12Grand Total Grand Total Total Responses = Severity Asterisk Total = _
