Adrenal Questionnaire

Adrenal Questionnaire

Adrenal Symptoms Questionnaire for Patients

The following questionnaire is a tool for helping to diagnose adrenal gland dysfunction that patients can quickly complete. The questionnaire is not meant to replace laboratory testing, but to be used in conjunction with standard tests used to measure adrenal function.

The questionnaire helps to identify if a person is in the “exhaustion” phase of adrenal depletion. In the “resistance” phase of adrenal dysfunction, cortisol levels tend to be high, and this results in some slightly different symptoms.

Please rank your symptoms according to the categories below:

0=Never

1=Occasionally (1-4 times per month)

2=Moderate in severity and occurs moderately frequently (1-4 times per week)

3=Intense in severity and occurs frequently (more than 4 times per week)

I get dizzy or see spots when standing up rapidly from a sitting or lying position.
I urinate more frequently than others and may need to get up at night.
I feel as though I might faint or black out.
I have chronic fatigue.
I have mitral valve prolapse or get heart palpitations.
I often have to force myself in order to keep going.
I have difficulty getting up in the morning.
I have low energy before the noon meal (approximately 11:00 a.m.).
I usually feel better after 6:00 p.m.
I often feel the best late at night because I get a ‘second wind’.
I have trouble getting to sleep. Dr. Scott Jurica info@drscottjurica.com 212-533-3631
I tend to wake up early (approximately 3:00 to 5:00 a.m.) and have trouble getting back to sleep.
I have vague feelings of being generally unwell for no apparent reason.
I have swelling in the extremities, such as the ankles.
I need to rest after times of mental , physical, or emotional stress.
I feel more tired after exercise or physical exertion, either soon or the next day.
My muscles feel weak and heavy more than I think they should.
I have chronic tenderness in my back near the bottom of my rib cage.
I have a weak back and/or weak knees.
I have restless extremities.
I am allergic to many things, such as food, animals and pollens.
My allergies are getting worse.
I get bags or dark circles under my eyes, which may be worse in the morning.
I have multiple chemical sensitivities.
I have asthma or get regular bouts of bronchitis, pneumonia, or other respiratory infections.
I have dermatographisim (a white line appears on my skin if I run my fingernail over it and persists for one minute).
I have an area of pale skin around my lips.
The skin on the palms of my hands and soles of my feet tends to be red/orange in color.
I tend to have dry skin.
I tend to get headaches and a sore neck and shoulders.
I am sensitive to bright light.
I frequently feel colder than others around me.
I have decreased tolerance for cold.
I have Raynaud’s syndrome (extremely cold hands/feet).
My temperature tends to be below normal when measured with a thermometer.
My temperature tends to fluctuate through the day.
I have low blood pressure.
I become hungry, confused, or shaky if I miss a meal.
I crave sugar, sweets, or desserts.
I use stimulants, such as tea or coffee, to get started in the morning.
I crave food high in fat and feel better with high-fat foods.
I need caffeine (chocolate, tea, coffee, colas) to get me through the day.
I often crave salt and/or foods high in salt, such as potato chips. Dr. Scott Jurica info@drscottjurica.com 212-533-3631
I feel worse if I eat sweets and no protein for breakfast.
I do not eat regular meals.
I eat fast-foods often.
I am sensitive to pharmaceutical or nutritional supplements.
I have taken steroid medications for a long term at high doses.
I have symptoms that improve after I eat.
I tend to be thin and find it difficult to put weight on.
I have feelings of hopelessness and despair or have been diagnosed with depression.
I lack motivation because I do not feel I have the energy to get things done.
I have decreased tolerance towards other people and tend to get irritated by them.
I get more than two colds or flues per year.
It takes me a long time to recover from illness.
I get rashes, dermatitis, eczema, psoriasis, or other skin conditions.
I have an autoimmune disease.
I have fibromyalgia.
I have had mononucleosis or been diagnosed with Epstein Barr virus.
I do not exercise regularly.
I have a history of large amounts of stress in my life.
I tend to be a perfectionist.
My health is negatively affected by stress.
I tend to avoid stressful situations for the sake of my health.
I am less productive at work than I used to be.
My ability to focus mentally is generally impaired.
Stressful situations hinder my ability to focus.
Stress causes me to become overly anxious.
I startle easily.
It can take me days or weeks to recover from a stressful event.
I tend to get digestive disturbances when tense.
I tend to get unexplained fears and phobias.
My sex drive is very low or non-existent.
My relationships at work and/or home tend to be strained.
My life contains insufficient time for fun and enjoyable activities.
I have little control over my life and I feel ‘stuck’.
I tend to get addicted easily to drugs, alcohol, or foods.
I suffer from post-traumatic stress disorder. Dr. Scott Jurica info@drscottjurica.com 212-533-3631
I have or have had an eating disorder.
I have gum disease and/or tooth infections or abcesses.
The next two questions are for women only.
I have symptoms of premenstrual syndrome (PMS).
My periods are irregular and/or affected by stress.
(Required)
info@lifeempowered.com
512-939-7960

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