Adrenal Fatigue Questionnaire : Dr. James L. Wilson's AdrenalFatigue.org

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.

Rating Scale

Adrenal Fatigue Questionnaire

Connect with Us:

About Us

Join Our Mailing List

Customer Service