Rating Scale

0 Never / rarely
1 Occasionally / Slightly
2 Moderate in intensity or frequency
3 Intense / severe or frequent

Past Now Predisposing Factors
I have experienced long periods of stress that have affected my well being.
I have had one or more severely stressful events that have affected my well being.
I have driven myself to exhaustion.
I overwork with little play or relaxation for extended periods.
I have had extended, severe or recurring respiratory infections.
I have taken long term or intense steroid therapy (corticosteroids).
I tend to gain weight, especially around the middle (spare tire).
I have a history of alcoholism and/or drug abuse.
I have environmental sensitivities.
I have diabetes (Type II, adult onset, NIDDM).
I suffer from post-traumatic stress syndrome.
* I suffer from anorexia.
I have one or more other chronic illnesses or diseases.

Past Now Key Signs and Symptoms
My ability to handle stress or pressure has decreased.
I am less productive at work.
I seem to have decreased in cognitive ability. I don't think as clearly as I used to.
My thinking is confused when hurried or under pressure.
I tend to avoid emotional situations.
I tend to shake or am nervous when under pressure.
I suffer from nervous stomach indigestion when tense.
I have many unexplained fears/anxieties.
My sex drive is noticeably less than it used to be.
I get lightheaded or dizzy when rising rapidly from a sitting or lying position.
I have feelings of graying or blacking out.
* I am chronically fatigued; a tiredness that is not usually relieved by sleep.
I feel unwell much of the time.
I notice that my ankles are swollen -- the swelling is worse in the evening.
I usually need to lie down or rest after sessions of psychological or emotional pressure/stress.
My muscles sometimes feel weaker than they should.
My hands and legs get restless -- experience meaningless body movements.
I have become allergic or have increased frequency/severity of allergic reactions.
When I scratch my skin a white line remains for a minute or more.
Small, irregular dark brown spots have appeared on my forehead, face, neck and shoulders.
* I sometimes feel weak all over.
I have unexplained and frequent headaches.
I am frequently cold.
* I have a decreased tolerance for cold.
* I have low blood pressure.
I often become hungry, confused, shaky or somewhat paralyzed under stress.
I have lost weight without reason while feeling very tired and listless.
I have feelings of hopelessness and despair.
I have decreased tolerance. People irritate me more.
The lymph nodes in my neck are frequently swollen (I get swollen glands on my neck).
* I have times of nausea and vomiting for no apparent reason.

Past Now Energy Patterns
I often have to force myself in order to keep going. Everything seems like a chore.
I am easily fatigued.
I have difficulty getting up in the morning (don't really wake up until about 10:00 AM).
I suddenly run out of energy.
I usually feel much better and fully awake after the noon meal.
I often have an afternoon low between 3:00-5:00 PM.
I get low on energy, moody or foggy if I do not eat regularly.
I usually feel my best after 6:00 PM.
I am often tired at 9:00-10:00 pm, but resist going to bed.
I like to sleep late in the morning.
My best, most refreshing sleep often comes between 7:00-9:00 AM.
I often do my best work late at night (early in the morning).
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.

Past Now Frequently Observed Events
I get coughs/colds that stay around for several weeks.
I have frequent, recurring bronchitis, pneumonia or other respiratory infections.
I get asthma, colds, and other respiratory involvements two or more times per year.
I frequently get rashes, dermatitis, or other skin conditions.
I have rheumatoid arthritis.
I have allergies to several things in the environment.
I have multiple chemical sensitivities.
I have chronic fatigue syndrome.
I get pain in the muscles of my upper back and lower neck for no apparent reason.
I get pain in the muscles in the side of my neck.
I have insomnia or difficulty sleeping.
I have fibromyalgia.
I suffer from asthma.

Past Now Food Patterns
I need coffee or some other stimulant to get going in the morning.
I often crave food high in fat and feel better with high fat foods.
I use high fat foods to drive myself.
I often use high fat foods and caffeine containing drinks (coffee, colas, chocolate) to drive myself.
I often crave salt and/or foods high in salt. I like salty foods.
I feel worse if I eat high potassium foods (like bananas, figs, raw potatoes), especially if I eat them in the morning.
I crave high protein foods (meats, cheeses).
I crave sweet foods (pies, cakes, pastries, doughnuts, dried fruits, candies or desserts.)
I feel worse if I miss or skip a meal.

Past Now Aggravating Patterns
I have constant stress in my life or work.
My dietary habits tend to be sporadic and unplanned.
My relationships at work and/or home are unhappy.
I do not exercise regularly.
I eat lots of fruit.
My life contains insufficient enjoyable activities.
I have little control over how I spend my time.
I restrict my salt intake.
I have gum and/or tooth infections or abscesses.
I have meals at irregular times.

Past Now Relieving Factors
I feel better almost right away once a stressful situation is resolved.
Regular meals decrease the severity of my symptoms.
I often feel better after spending a night out with friends.
I often feel better if I lie down.

Mon-Fri 7:30am to 4:00pm (MST)   800-357-5027 or 520-748-0388

Adrenal Fatigue Questionnaire