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)




1
I get dizzy or see spots when standing up rapidly from a sitting or lying position.
NeverOccasionallyModerateIntense

 

2
I urinate more frequently than others and may need to get up at night.
NeverOccasionallyModerateIntense
3
I feel as though I might faint or black out.
NeverOccasionallyModerateIntense

 

4
I have chronic fatigue.
NeverOccasionallyModerateIntense
5
I have mitral valve prolapse or get heart palpitations.
NeverOccasionallyModerateIntense

 

6
I often have to force myself in order to keep going.
NeverOccasionallyModerateIntense
7
I have difficulty getting up in the morning.
NeverOccasionallyModerateIntense

 

8
I have low energy before the noon meal (approximately 11:00 a.m.).
NeverOccasionallyModerateIntense
9
I have low energy in the late afternoon between 3:00-5:00 p.m.
NeverOccasionallyModerateIntense

 

10
I usually feel better after 6:00 p.m.
NeverOccasionallyModerateIntense
11
I often feel the best late at night because I get a ‘second wind’.
NeverOccasionallyModerateIntense

 

12
I have trouble getting to sleep.
Dr. Scott Jurica info@drscottjurica.com 212-533-3631
NeverOccasionallyModerateIntense
13
I tend to wake up early (approximately 3:00 to 5:00 a.m.) and have trouble getting back to sleep.
NeverOccasionallyModerateIntense

 

14
I have vague feelings of being generally unwell for no apparent reason.
NeverOccasionallyModerateIntense
15
I have swelling in the extremities, such as the ankles.
NeverOccasionallyModerateIntense

 

16
I need to rest after times of mental , physical, or emotional stress.
NeverOccasionallyModerateIntense
17
I feel more tired after exercise or physical exertion, either soon or the next day.
NeverOccasionallyModerateIntense

 

18
My muscles feel weak and heavy more than I think they should.
NeverOccasionallyModerateIntense
19
I have chronic tenderness in my back near the bottom of my rib cage.
NeverOccasionallyModerateIntense

 

20
I have a weak back and/or weak knees.
NeverOccasionallyModerateIntense
21
I have restless extremities.
NeverOccasionallyModerateIntense

 

22
I am allergic to many things, such as food, animals and pollens.
NeverOccasionallyModerateIntense
23
My allergies are getting worse.
NeverOccasionallyModerateIntense

 

24
I get bags or dark circles under my eyes, which may be worse in the morning.
NeverOccasionallyModerateIntense
25
I have multiple chemical sensitivities.
NeverOccasionallyModerateIntense

 

26
I have asthma or get regular bouts of bronchitis, pneumonia, or other respiratory infections.
NeverOccasionallyModerateIntense
27
I have dermatographisim (a white line appears on my skin if I run my fingernail over it and persists for one minute).
NeverOccasionallyModerateIntense

 

28
I have an area of pale skin around my lips.
NeverOccasionallyModerateIntense
29
The skin on the palms of my hands and soles of my feet tends to be red/orange in color.
NeverOccasionallyModerateIntense

 

30
I tend to have dry skin.
NeverOccasionallyModerateIntense
31
I tend to get headaches and a sore neck and shoulders.
NeverOccasionallyModerateIntense

 

32
I am sensitive to bright light.
NeverOccasionallyModerateIntense
33
I frequently feel colder than others around me.
NeverOccasionallyModerateIntense

 

34
I have decreased tolerance for cold.
NeverOccasionallyModerateIntense
35
I have Raynaud’s syndrome (extremely cold hands/feet).
NeverOccasionallyModerateIntense

 

36
My temperature tends to be below normal when measured with a thermometer.
NeverOccasionallyModerateIntense
37
My temperature tends to fluctuate through the day.
NeverOccasionallyModerateIntense

 

38
I have low blood pressure.
NeverOccasionallyModerateIntense
39
I become hungry, confused, or shaky if I miss a meal.
NeverOccasionallyModerateIntense

 

40
I crave sugar, sweets, or desserts.
NeverOccasionallyModerateIntense
41
I use stimulants, such as tea or coffee, to get started in the morning.
NeverOccasionallyModerateIntense

 

42
I crave food high in fat and feel better with high-fat foods.
NeverOccasionallyModerateIntense
43
I need caffeine (chocolate, tea, coffee, colas) to get me through the day.
NeverOccasionallyModerateIntense

 

44
I often crave salt and/or foods high in salt, such as potato chips.
Dr. Scott Jurica info@drscottjurica.com 212-533-3631
NeverOccasionallyModerateIntense
45
I feel worse if I eat sweets and no protein for breakfast.
NeverOccasionallyModerateIntense

 

46
I do not eat regular meals.
NeverOccasionallyModerateIntense
47
I eat fast-foods often.
NeverOccasionallyModerateIntense

 

48
I am sensitive to pharmaceutical or nutritional supplements.
NeverOccasionallyModerateIntense
49
I have taken steroid medications for a long term at high doses.
NeverOccasionallyModerateIntense

 

50
I have symptoms that improve after I eat.
NeverOccasionallyModerateIntense
51
I tend to be thin and find it difficult to put weight on.
NeverOccasionallyModerateIntense

 

52
I have feelings of hopelessness and despair or have been diagnosed with depression.
NeverOccasionallyModerateIntense
53
I lack motivation because I do not feel I have the energy to get things done.
NeverOccasionallyModerateIntense

 

54
I have decreased tolerance towards other people and tend to get irritated by them.
NeverOccasionallyModerateIntense
55
I get more than two colds or flues per year.
NeverOccasionallyModerateIntense

 

56
It takes me a long time to recover from illness.
NeverOccasionallyModerateIntense
57
I get rashes, dermatitis, eczema, psoriasis, or other skin conditions.
NeverOccasionallyModerateIntense

 

58
I have an autoimmune disease.
NeverOccasionallyModerateIntense
59
I have fibromyalgia.
NeverOccasionallyModerateIntense

 

60
I have had mononucleosis or been diagnosed with Epstein Barr virus.
NeverOccasionallyModerateIntense
61
I do not exercise regularly.
NeverOccasionallyModerateIntense

 

62
I have a history of large amounts of stress in my life.
NeverOccasionallyModerateIntense
63
I tend to be a perfectionist.
NeverOccasionallyModerateIntense

 

64
My health is negatively affected by stress.
NeverOccasionallyModerateIntense
65
I tend to avoid stressful situations for the sake of my health.
NeverOccasionallyModerateIntense

 

66
I am less productive at work than I used to be.
NeverOccasionallyModerateIntense
67
My ability to focus mentally is generally impaired.
NeverOccasionallyModerateIntense

 

68
Stressful situations hinder my ability to focus.
NeverOccasionallyModerateIntense
69
Stress causes me to become overly anxious.
NeverOccasionallyModerateIntense

 

70
I startle easily.
NeverOccasionallyModerateIntense
71
It can take me days or weeks to recover from a stressful event.
NeverOccasionallyModerateIntense

 

72
I tend to get digestive disturbances when tense.
NeverOccasionallyModerateIntense
73
I tend to get unexplained fears and phobias.
NeverOccasionallyModerateIntense

 

74
My sex drive is very low or non-existent.
NeverOccasionallyModerateIntense
75
My relationships at work and/or home tend to be strained.
NeverOccasionallyModerateIntense

 

76
My life contains insufficient time for fun and enjoyable activities.
NeverOccasionallyModerateIntense
77
I have little control over my life and I feel ‘stuck’.
NeverOccasionallyModerateIntense

 

78
I tend to get addicted easily to drugs, alcohol, or foods.
NeverOccasionallyModerateIntense
79
I suffer from post-traumatic stress disorder.
Dr. Scott Jurica info@drscottjurica.com 212-533-3631
NeverOccasionallyModerateIntense

 

80
I have or have had an eating disorder.
NeverOccasionallyModerateIntense
81
I have gum disease and/or tooth infections or abcesses.
NeverOccasionallyModerateIntense

 

82
The next two questions are for women only.
NeverOccasionallyModerateIntense
83
I have symptoms of premenstrual syndrome (PMS).
NeverOccasionallyModerateIntense

 

84
My periods are irregular and/or affected by stress.
NeverOccasionallyModerateIntense