Adrenal Self Assessment

Adrenal Questionnaire

Please enter the appropriate response to each statement in the columns below:

0 = Never/Rarely

1 = Occasionally

2 = Moderate in intensity or frequency

3 = Almost always or extremely intense

Chronic Stress & Stressors

   Past     Now

l. _____   _____ 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 have a history of alcoholism and/or drug abuse.

8. ____   _____ I suffer from post traumatic stress syndrome.

9. ____   _____ I have one or more other chronic illnesses or diseases.

    _____   _____ Total

Signs & Symptoms

1. _____   _____ My ability to handle stress and pressure has decreased.

2. _____   _____ I am less productive at work.

3. _____   _____ I seem to have decreased in cognitive ability.  I don’t think as clearly as I used to.

4. _____   _____ My thinking is confused when hurried or under pressure.

5. _____   _____ I tend to avoid emotional situations.

6. _____   _____ I tend to shake or am nervous when under pressure.

7. _____   _____ I suffer from nervous stomach indigestion when tense.

8. ____   _____ I get lightheaded or dizzy when rising rapidly from a sitting or lying position.

9. ____   _____ I have feelings of graying out or blacking out.

10. ____   _____ I am chronically fatigued; a tiredness that is not usually relived by sleep.

11. ____   _____ I notice that my ankles are sometimes swollen – the swelling is worse in the evening.

12. ____   _____ I usually need to lie down or rest after sessions of psychological or emotional pressure/stress.

13. ____   _____ My muscles sometimes feel weaker than they should.

14. ____   _____ I feel restless, always finding something to do and find it hard to rest.

15. ____   _____ Small irregular dark brown spots have appeared on my forehead, face, neck and shoulders.

16. ____   _____ I sometimes feel weak all over.

17. ____   _____ I have decreased tolerance for cold.

18. ____   _____ I have low blood pressure.

19. ____   _____ I often become angry, confused, shaky or somewhat paralyzed under stress.

20. ____   _____ I have lost weight without reason while feeling very tired and listless.

21. ____   _____ I have decreased tolerance.  People irritate me more.

22. ____   _____ The lymph nodes in my neck are frequently swollen.

23. ____   _____ I have gained weight for no apparent reason.

    _____   _____ Total

Circadian Rhythm & Energy

l. _____    _____ I often have to force myself in order to keep going.  Everything seems like a chore.

2. _____   _____ I am easily fatigued.

3. _____   _____ I have difficulty getting up in the morning (don’t 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 often have an afternoon low  or crash between 3:00 – 5:00 PM.

7. _____   _____ I get low energy, moody or foggy if I do not eat regularly.

8. _____   _____ I am often tired at 9:00 – 10:00 PM, but resist going to bed.

9. _____   _____ I like to sleep late in the morning.

10. ____   _____ My most refreshing sleep often comes between 7:00 – 9:00 AM.

11. ____   _____ I usually feel my best after 6 PM.

12. ____   _____ I often do my best work late at night (early in the morning).

13. ____   _____ 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.

14. ____   _____ I often wake up during the night.

15. ____   _____ I have a difficult time falling asleep.

16. ____   _____ I often use caffeine containing drinks to drive myself such as coffee, teas, colas, sodas and chocolate.

17. ____  ______ Feel fatigued and tired by mid-morning.

18. ____  ______ Pain during sleep.

19. ____  ______ Don’t feel rested even after 6 or more hours of sleep.

20. ____  ______ Don’t feel like eating first AM.

21. ____  _____ Need caffeine to get going in AM.

22. ____   _____ Hard time falling asleep.

     _____   _____ Total

Health Consequences

1. _____   _____ I have multiple chemical sensitivities.

2. _____   _____ I get asthma, colds and other respiratory issues two or more times per year.

3. _____   _____ I have allergies to several things in the environment.

4. _____   _____ I have or have had chronic fatigue syndrome.

5. _____   _____ I suffer from asthma.

7.  ____   _____ I suffer from hay fever.

9.  ____   _____ My allergies are becoming worse (more severe, frequent or diverse).

10.____   _____ I have a chronic inflammatory condition such as an autoimmune condition, arthritis, diabetes, osteoporosis, heart issues, or chronic pain.

11. ____   _____ I have chronic gastrointestinal and digestive issues such as gas, bloating and/or heartburn.

12. ____   _____ I have food intolerances.

13. ____   _____ Weight gain

14. ____  _____ Gastric ulcer

15. ____  _____ Memory issues

16. ____  _____ I have been diagnosed with post traumatic stress disorder.

17. ____  _____ I have high or low blood pressure.

18. ____  _____ I have sensitivity to light and/or sound.

19. ____  _____ I have diabetes (type II, adult onset, NKDDM)

20. ____  _____ I suffer from anorexia

21. ____  _____ I tend to gain weight, especially around the middle.

    _____   _____ Total

Lifestyle and Dietary Factors

l. _____   _____ I have constant stress in my life or 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. _____   _____ My life contains insufficient enjoyable activities.

6. _____   _____ I have little control over how I spend my time.

8. _____   _____ I have meals at irregular times.

9. _____   _____ I have increasing symptoms of premenstrual syndrome (cramps, bloating,

10. _____   _____ I often crave food high in fat and feel better with high fat foods.

11. _____   _____ I use fatty foods to motivate myself.

12. _____   _____ I crave sweet foods (pies, cakes, pastries, doughnuts, dried fruits, candy or desserts).

13. _____   _____ I feel worse if I skip a meal.

14. ____   _____ I eat lots of fruit.

15. ____  _____ I feel sleepy after meals, especially a high starch meal.

    _____   _____ Total

The greater the number of questions that you responded to, the greater your adrenal fatigue. 

A score of 30, you may have slight adrenal fatigue or none at all. 

Between 31 – 65, you have a mild degree of adrenal fatigue.

Between 66 – 85, your adrenal fatigue is moderate. 

Above 130, then consider yourself to be suffering from adrenal fatigue. 

Now, compare the total points for each section. Watch for the predominating symptoms and in which areas they predominate. This will assist you in developing your own recovery program.

***Please note that by the time you experience sound and light sensitivity, an inability to handle the least amount of stress, your body is experiencing a chronic inflammatory state of stress – no matter what other symptoms you have.