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.