Adrenal Questionnaire

by THOMAS on Apr 3, 2012 • 2:32 am

Instructions: please enter the appropriate response to the statements below

 

Date:__________________

 

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.

 

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 stress disorder.

 

12. _____ ____ I suffer from anorexia. *