1、Adrenal QuestionnaireTodays Date: _Instructions: Please enter the appropriate response number to each statement in the columns below.0 = Never/Rarely1 = Occasionally/Slightly2 = Moderate in Intensity or Frequency3 = Intense/Severe or FrequentI have not felt well since _ when _(date) (describe event,
2、 if any)Predisposing FactorsPast 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 has affected my well being. (Mental,emotional or physical events)3. _ _ I have driven myself to exhaustion.4. _ _ I over
3、work 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 o
4、f alcoholism a tiredness that is not usually relieved by sleep.*13. _ _ I feel unwell much of the time.14. _ _ My ankles are sometimes swollen Swelling isworse in the evening.15. _ _ I usually need to lie down or rest after sessions of psychological or emotional pressure/stress.16. _ _ My muscles so
5、metimes feel weaker than normal. 17. _ _ My hands and legs get restless experience meaningless body movements or twitches.18. _ _ I have become allergic or have increased frequency/severity of allergic reaction.19. _ _ When I scratch my skin, a white line remains for a minute or more.20. _ _ Small i
6、rregular 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 often relieved by eating sweets or alcohol.23. _ _ I am frequently cold.24. _ _ I have decreased tolerance for cold.*25. _ _ I ha
7、ve 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 for other people. I am easily
8、 irritated by their words/actions.30. _ _ The lymph nodes (or glands) in my neck are often swollen.31. _ _ I have times of nausea and / or vomiting for no apparent reason.*32. _ _ I occasionally experience heart palpitations.33. _ _ I have difficulty “holding” chiropractic adjustments.34. _ _ I ofte
9、n yawn in the afternoon.35. _ _ I perspire easily and/or experience cold sweats.36. _ _ I suffer from poor circulation.37. _ _ Its difficult for me to say “no” to others.38. _ _ I do not tolerate much exercise.39. _ _ I have dark circles under my eyes.40. _ _ My eyes are very sensitive to bright lig
10、ht.41. _ _ I experience loss of vision when standing suddenly.42. _ _ My sex drive is noticeably less than it used to be._ _ TotalEnergy PatternsPast Now1. _ _ I often have to “force myself” to keep going.Everything seems like a heavy chore.2. _ _ I am easily fatigued. Have little to no endurance.3.
11、 _ _ I have difficulty getting up in the morning (dont really wake up until about 10:00 am).4. _ _ I suddenly run out of energy.5. _ _ I usually feel much better and fully awake after the noon meal.6. _ _ I have an afternoon low between 3:00 5:00 pm.7. _ _ I get low energy, moody or foggy if I do no
12、t eat regularly.8. _ _ I usually feel my best after 6:00 pm.9. _ _ I am often tired at 9:00-10:00 pm, but resist going to bed.10. _ _ I like to sleep late in the morning.11. _ _ My best, most refreshing sleep often comes between 7:00-9:00 am.12. _ _ I often do my best work late at night (early in th
13、e morning).13. _ _ If I dont go to bed by 10:30 pm, I often get my “second wind” and wont go to bed until 1:00 2:00 am. _ _ TotalFrequently Observed EventsPast Now1. _ _ I get coughs/colds that often “hang around”for several weeks.2. _ _ I have frequent or recurring bronchitis, pneumonia or other re
14、spiratory infections.3. _ _ I get asthma, colds and other respiratory involvements two or more times per year.4. _ _ I often get rashes, dermatitis, or other skin conditions such as eczema or psoriasis.5. _ _ I have been diagnosed with rheumatoid arthritis.6. _ _ I have allergies to several things i
15、n the environment.7. _ _ I have multiple chemical sensitivities.8. _ _ I have chronic fatigue syndrome.9. _ _ I often have pain when getting up in the morning in the upper back, neck, and/or head for no apparentreason.10. _ _ I get pain in the muscles on the sides of my neck.11. _ _ I have insomnia
16、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 palms of my hands and/or fingertips are often re
17、d.18. _ _ I bruise more easily than I used to.19. _ _ I have tenderness in my back near my spine at the bottom of my rib cage when pressed.20. _ _ I have swelling under my eyes upon arising thatgoes away after a couple of hours. 21. _ _ I often awaken for no particular reason sometime during the nig
18、ht.The next two questions are for women only21. _ _ I have increasing symptoms of PMS such as cramps, bloating, moodiness, irritability, headaches, tiredness, etc. before my period (only some of these need be present.).22. _ _ My periods are generally heavy but they often stop, or almost stop, on th
19、e 4th day, only to restart profusely on the 5th or 6th day._ _ TotalFood PatternsPast Now1. _ _ 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 h
20、igh 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 eat high potassium foods (like bananas, figs, raw potatoes), especially if I eat them in the morning.7. _ _ I crave
21、 high protein foods (meats, cheeses).8. _ _ I crave sweet foods (pies, cakes, pastries, dried fruits, candies, etc.).9. _ _ I feel worse if I miss or skip a meal.10. _ _ I often feel tired one to three hours after eating._ _ TotalAggravating FactorsPast Now1. _ _ I have constant stress in my life or
22、 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 fruits, sweets, and/or starchy foods on adaily basis.6. _ _ My life contains insufficient enjoyable activities.7. _ _ I have little
23、 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 often go many hours with no substantial food. My meals are always at irregular times.11. _ _ I have soft tissue and/or joint inflammation on a regular basis.12. _ _ I s
24、uffer from bone deformities or other structural abnormalities that create on-going pain and inflammation.13. _ _ I am exposed to natural or man-made pollutants on a regular basis.14. _ _ I take prescription or recreational drugs on a regular basis. _ _ TotalRelieving FactorsPast Now1. _ _ I feel bet
25、ter almost right away once a stressful situation is resolved.2. _ _ Maintaining regular meals and/or snacks willdecrease the severity and frequency of my symptoms.3. _ _ I often feel better after spending a night out with friends.4. _ _ I often feel better if I lie down for a short time.5. _ _ Other relieving factors _ _ Total
