Adrenal Questionnaire
Today's date: _____________
Instructions: Please enter the appropriate response number to each statement in columns below.
0 = Never / Rarely
1 = Occasionally
2 = Moderate in Intensity or Frequency
3 = Intense / Severe or Frequent
I have not felt well since _________
(date) when ____________________________
(describe event, if any)
Key Signs & Symptoms
------Past Now
01 _____ _____ My ability to handle stress and pressure has decreased.
02 _____ _____ I am less productive at work.
03 _____ _____ I seem to have decreased in cognitive ability. I don’t think as clearly as I used to.
04 _____ _____ My thinking is confused when under pressure.
05 _____ _____ I tend to avoid emotional situations.
06 _____ _____ I tend to shake or am nervous when under pressure.
07 _____ _____ I suffer from nervous stomach indigestion when tense.
08 _____ _____ I have many unexplained fears / anxieties.
09 _____ _____ I My sex drive is noticeably less than it used to be.
10 _____ _____ I get lightheaded or dizzy when rising rapidly from a sitting or lying position.
11 _____ _____ I have feelings of graying out or blacking out.
12 _____ _____ I am chronically fatigue; a tiredness that is not usually relieved by sleep.*
13 _____ _____ I feel unwell much of the time.
14 _____ _____ I notice that my ankles are sometimes swollen – the swelling is worse in the evening.
15 _____ _____ I usually need to lie down or rest after sessions of psychological or emotional pressure/stress.
16 _____ _____ My muscles sometimes feel weaker than they should.
17 _____ _____ My hands and legs get restless - experience meaningless body moves.
18 _____ _____ I have become allergic or have increased frequency/severity of allergic reactions.
19 _____ _____ When I scratch my skin, a white line remains for a minute or more.
20 _____ _____ Small irregular dark brown spots have appeared on my forehead, face, neck and shoulders.
21 _____ _____ I sometimes feel weak all over.*
22 _____ _____ I have unexplained and frequent headaches.
23 _____ _____ I am frequently cold.
24 _____ _____ I have decreased tolerance for cold.*
25 _____ _____ I have low blood pressure.*
26 _____ _____ I often become hungry, confused, shaky or somewhat paralyzed under stress.
27 _____ _____ I have lost weight without reason while feeling very tired and listless.
28 _____ _____ I have feelings of hopelessness or despair.
29 _____ _____ I have decreased tolerance. People irritate me more.
30 _____ _____ The lymph nodes in my neck are frequently swollen (I get swollen glands on my neck).
31 _____ _____ I have times of nausea and vomiting for no apparent reason.*
32 _____ _____
Total
Energy Patterns
-----Past Now
01 _____ _____ I often have to force myself in order to keep going. Everything seems like a chore.
02 _____ _____ I am easily fatigued.
03 _____ _____ I have difficulty getting up in the morning (don’t really wake up until about 10:00 AM).
04 _____ _____ I suddenly run out of energy.
05 _____ _____ I usually feel much better and fully awake after the noon meal.
06 _____ _____ I often have an afternoon low between 3:00 – 5:00 PM.
07 _____ _____ I get low energy, mood or foggy if I do not eat regularly.
08 _____ _____ I usually feel my best after 6:00 PM.
09 _____ _____ I am often tired at 9:00 – 10:00 PM, but resist going to bed.
10 _____ _____ I like to sleep late in the morning.
11 _____ _____ My best, most refreshing sleep often comes between 7:00 – 9:00 AM.
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 _____ _____
Total
Food Patterns
----Past Now
1 _____ _____ I need coffee or some other stimulant to get going in the morning.
2 _____ _____ I often crave food high in fat and feel better with high fat foods.
3 _____ _____ I use high fat foods to drive myself.
4 _____ _____ I often use high fat foods and caffeine containing drinks (coffee, colas, chocolate) to drive myself.
5 _____ _____ I often crave salt and / or foods high in salt. I like salty foods.
6 _____ _____ I feel worse if I eat high potassium foods (like bananas, figs, raw potatoes), especially if I eat them in the morning.
7 _____ _____ I crave high protein foods (meats, cheeses).
8 _____ _____ I crave sweet foods (pies, cake, pastries, doughnuts, dried fruits, candies or desserts).
9 _____ _____ I feel worse if I miss or skip a meal.
1 _____ _____
Total
Frequently observed Events
------Past Now
01 _____ _____ I get coughs/colds that stay around for several weeks.
02 _____ _____ I have frequent or recurring bronchitis, pneumonia or other respiratory infections.
03 _____ _____ I get asthma, colds and other respiratory involvement two or more times a year.
04 _____ _____ I frequently get rashes, dermatitis, or other skin conditions.
05 _____ _____ I have rheumatoid arthritis.
06 _____ _____ I have allergies to several things in the environment.
07 _____ _____ I have multiple chemical sensitivities.
08 _____ _____ I have chronic fatigue syndrome.
09 _____ _____ I get pain in my muscles on my upper back and lower neck for no apparent reason.
10 _____ _____ I get pain in my muscles on the side of my neck.
11 _____ _____ I have insomnia or difficulty sleeping.
12 _____ _____ I have fibromyalgia.
13 _____ _____ I suffer from asthma.
14 _____ _____ I suffer from hay fever.
15 _____ _____ I suffer from nervous breakdowns
16 _____ _____ My allergies are becoming worse (more severe, frequent or diverse).
17 _____ _____ That fat pads on my palms of my hands are/or tips of my fingers are often red.
18 _____ _____ I bruise more easily than I used to.
19 _____ _____ I have a tenderness in my back near my spine at the bottom of my rib cage when pressed.
20 _____ _____ I have swelling under my eyes upon rising that goes away after I have been up for å couple of hours.
The next 2 questions are for women only
------Past Now
21 _____ _____ I have increased symptoms of menstrual syndrome (PMS) such as cramps, bloating, moodiness, irritability, emotional instability,
______________headaches, tiredness, and/or intolerance before my period (only some of these need be present).
22 _____ _____ My periods are generally heavy but they often stop, or almost stop, on fourth day, only to start up profusely on the 5
th or 6
th day.
23 _____ _____
Total
Aggravating Factors
------Past Now
01 _____ _____ I have constant stress in my life or work.
02 _____ _____ My dietary habits tend to be sporadic and unplanned.
03 _____ _____ My relationships at work and/or home are unhappy.
04 _____ _____ I do not exercise regularly.
05 _____ _____ I eat lots of fruit.
06 _____ _____ My life contains insufficient enjoyable activities.
07 _____ _____ I have little control over how I spend my time.
08 _____ _____ I restrict my salt intake.
09 _____ _____ I have gum and/or tooth infections or abscesses.
10 _____ _____ I have meals at irregular times.
11 _____ _____
Total
Relieving Factors
-----Past Now
1 _____ _____ I feel better right away once a stressful situation is solved.
2 _____ _____ Regular meals decrease the severity of my symptoms.
3 _____ _____ I often feel better after spending a night out with my friends.
4 _____ _____ I often feel better if I lie down.
5 _____ _____ Other relieving factors ____________________________________________________________ ____________________
6 _____ _____
Total
Scoring and Interpretation of the Questionnaire
A lot of the information can be obtained from questionnaire. Follow the instructions below to score your questionnaire correctly. Then proceed to interpretation section.
Total Numbers of Questions Answered
1. First count total number of questions in each section that you answered with my number other than zero. Enter the “
Past” and “
Now” totals separately, entering each in appropriate boxes for each section of the “
Total number of questions answered” scoring chart on the next page. For example, if you answered a total of
21 questions in the “Past” column and
27 questions in the “
Now” column of “
Key Signs and Symptoms” with a 1, 2, or 3, your total number of questions answered score for the “
Past” column in the section would be “
21” and for the “Now” column would be “
27”. Note that there are no entries for the first section of questionnaire entitled “
Predisposing Factors”. This section is dealt with separately and is not included in summary below. Therefore, you first entry into summary boxes will be for the “
Key Signs and Symptoms” section.
2. After you have finished entering the number of questions answered in both columns for each section, sum all the numbers for each column and the total in the “Grand Total” – Total Responses” boxes on the bottom row of scoring chart.
3. All boxes in the “
Total Number of Questions Answered” chart should be filled.
Then go on to the next part of the scoring.
Total Number of Questions Answered
| Name of Section |
Total Responses |
|
Past |
Now |
Key Signs & Symptoms
Number of questions – 31 |
|
|
Energy Patterns
Number of questions – 13 |
|
|
Food Patterns
Number of questions – 9 |
|
|
Frequently Observed Events
Number of questions –
20 for men 22 for women |
|
|
Aggravating factors
Number of questions – 10 |
|
|
Relieving Factors
Number of questions – 4 |
|
|
| Grand Total – Total Responses |
|
|
The questionnaire is a valuable tool for determining if you have adrenal fatigue or not, and if you do, the severity of your syndrome. Of course, the accuracy of its interpretation depends upon you completing every section as accurately and honest as possible. Because there is such diversity in how individuals experience adrenal fatigue, a wide variety of signs and symptoms have been included. Some people have only the minimal number of symptoms, but the symptoms they do have are severe. Others experience a great number of symptoms, but most of their symptoms are relatively mild. That is why there are two kinds of scores to indicate adrenal fatigue.
Total Numbers of Questions Answered:
This gives you a general “Yes or No” answer to the question. “Do I have adrenal fatigue?” Look at your “Grand Total” – Total responses” scores in the first scoring cart (Total Number of Questions Answered). The purpose of this is to see the number of total signs and symptoms of adrenal fatigue you have. There are a total of 87 questions for men and 89 for women in the questionnaire.
If you respond to more than 26 (men) and 32 (women) of the questions, (regardless of which severity response number you gave the question), you have some degree of adrenal fatigue. The greater the number of questions that you responded to, the greater your adrenal fatigue. If you responded affirmatively to less than 29 of the questions, it is unlikely adrenal fatigue is your problem. People who do have adrenal fatigue, may still experience a few of these indications in their lives, but not many of them. If your symptoms do not include fatigue or decreased ability to handle stress, then you are probably not suffering from adrenal fatigue.
Total Points:
The total points are used to determine the degree of severity of your adrenal fatigue. If you ranked every question as 3 (the worst) your points would be 261 for men and 267 for women. If you scored under 40, you either have only slight adrenal fatigue or none at all. If you scored 44-87 for men and 45-88 for women, then overall you have a mild degree of adrenal fatigue. This does not mean that some individual symptoms are not severe, but overall your symptoms picture reflects mildly fatigue adrenals.
If you scored between 88-130 for men and 89-132 for women, your adrenal fatigue is moderate. If you score above 139 for men and 132 for women, then consider yourself to be suffering from severe adrenal fatigue. Now compare the total points of different sections with each other.
This allows you to see if 1 or 2 sections stand out as having more signs and symptoms than others. If you have a predominating group of symptoms, they will be the most useful ones for you to watch as indicators as you improve. Seeing which section stand out will also be helpful in developing your own recovery program.
Severity Index:
The Severity Index is calculated by simply dividing the total points by the total number of questions you answered in the affirmative. It gives an indication of how severely you experience the signs and symptoms, with 1.0 – 1.6 being mild, 1.7 – 2.3 being moderate, and 2.4 up being severe. This number is especially useful for those who suffer from only a few signs and symptoms, but yet are considerable debilitated by them.
Past vs. Now:
Now compare the total points in the “Past” column to be the total points in the “Now” column. The difference indicates the direction your adrenal health is taking. If the numbers in the “Past” column is greater than the number in the “Now” column, then you are slowly healing from hypoadrenia. It is a good sign you are healing, but you will still want to read the following chapters to accelerate your improvement. If the number in the “Now” column is greater than the number in the “Past” column, your adrenal glands are on a downhill course and you need to take immediate action before you finish reading the rest of the book.
Asterisk Total:
Finally, add the actual numbers you put beside the questions marked by asterisks (*) for “Now” column, If this total is more than 9, you are likely suffering a relatively severe form of adrenal fatigue. If its total is 12, and you answer yes to more than 2 of the questions below, you have many of the indications of true Addison’s disease and should consult a physician in addition to doing the things in this book. Be sure to read the section below, “Approaching Your Doctor”, as well as appropriate sections in this book before consulting a physician.
Answer the following questions only if you scored more than 12 on the questions marked with asterisk (*).
Additional Symptoms (ones that are not present now)
The areas on my body listed below have become bluish-black in color.
_____ Inside of lips
_____ Vagina
_____ Around hips
_____ Around nipples
_____ I have frequent unexplained diarrhea.
_____ I have increased darkening around the bony areas, at folds in my skin, scars and the
_____ creases in my joints.
_____ I have light colored patches on my skin where the skin has lost its usual color.
_____ I easily become dehydrated.
_____ I have faint spells.
Interpretation of the “Predisposing Factors” Section:
Predisposing Factor
-----Past Now
01 _____ _____ I have experienced long periods of stress that have affected my well being.
02 _____ _____ I have had one more severely stressful events that have affected my well being.
03 _____ _____ I drive myself to exhaustion.
04 _____ _____ I overwork with little play or relaxation for extended periods.
05 _____ _____ I have extended, severe or recurring respiratory infections.
06 _____ _____ I have taken long term or intense steroid therapy (corticosteroids).
07 _____ _____ I tend to gain weight, especially around the middle (spare tire).
08 _____ _____ I have a history of alcoholism &/or drug abuse.
09 _____ _____ I have environmental sensitivities.
10 _____ _____ I have diabetes (type 2, adult onset, NIDDM).
11 _____ _____ I suffer from post traumatic distress syndrome.
12 _____ _____ I suffer from anorexia.*
13 _____ _____ I have one or more chronic illnesses or diseases.
14 _____ _____
Total
This section helps determine which factor led to the development of your adrenal fatigue. There may have been only one factor or there may have been several, but the number does not matter. One severely stressful incident can be all it takes for someone to develop adrenal fatigue, although typically it is more. This list is not exhaustive, but the items listed in this section are the most common factors that led to adrenal fatigue. Use this section to better understand how your adrenal fatigue developed. Seeing how it started often makes clearer what actions you can take to successfully recover from it. The section also leads into a following section that explores in more depth how your adrenal fatigue developed.
Approaching your Doctor:
Now that you have decided that you have some form of adrenal fatigue, it is only natural for you to run and tell your doctor. Or you may want the doctor to have your do further tests. If you skipped over the last chapter, a word of caution before you share your newfound revelations with him or her. First your doctor may not believe that adrenal fatigue exists. Second, if he vaguely recognizes the term, he may want to run the test for Addison’s disease. Since only 4 in 100,000 have Addison’s disease, chances are you will pass the test and he will conclude that there is nothing wrong with you. He may give you some tranquilizers, send you to a psychiatrist, tell you to quit reading the self-help books, or offer other unhelpful advice. Even many alternative physicians are not yet aware of the problems of adrenal fatigue. Believe it or not, the fact adrenal fatigue is so common and so pervasive makes it more difficult to recognize. But regardless of what your doctor says, adrenal fatigue is real and the questionnaire in this book is a valuable tool in identifying its presence and severity. Although this book is written for people who have no medical background, it is based on a solid foundation of more than 2,400 scientific and clinical references relating to adrenal fatigue. However, the truly important questions are not how many studies relate to adrenal fatigue or whether or not your doctor recognizes it. The important questions are do you suffer from adrenal fatigue and if so, what can you do about it. To help you answer the question, read on. The next chapter will help you determine how you came to have adrenal fatigue.
TRANSLATED BY PERMISSION FROM THE AUTHOR OF THE BOOK ADRENAL FATIGUE THE 21ST CENTURY STRESS SYNDROME
BY JAMES L. WILSON, N.D., D.C., PH.D. PUBLISHER: SMART PUBLICATIONS ISBN 1-890572-15-2
Jeg synes denne sjekklisten er så viktig at jeg har lagt den inn for å gjøre den lettere tilgjengelig for folk. Leger i alminnelighet har i sin utdannelse ikke lært å forstå eller å ta seg av binyretretthet. Noen ganger blir det som
å slå hodet i veggen å tilnærme seg problemet med legen - akkurat som beskrevet i Approaching Your Doctor. Legen har av en eller annen grunn mye lettere for å henvise "mulige slitne binyrer" til psykolog.
Det blir som å fylle bensintanken med vann og ikke skjønne hvorfor bilen ikke kjører flau1.
Boken er absolutt å anbefale. Den kostet under hundrelappen på
capris.noxx9
