Functional health

Designed by Dr. Jack Tips (Ph.D., C.C.N.) for clinical use. © 2014 by Apple-A-Day Press. www.appleadaypress.com
Permission to reprint universally granted.


Adrenal Stress Questionnaire

The fields denoted with * are compulsory fields

* Name & Surname
* Telephone
* Email

For each statement that applies to you, enter a ' X '.

1.

Stressful events occurring that affect well-being

2.

I drive myself to exhaustion

3.

Work and overwork with little time for recreation, vacation

4.

Weight gain around the middle

5.

Frequent upper respiratory infections

6.

In the past 10 years, have taken Rx steroids for more than 10 days

7.

History, or current, excessive alcohol or recreational drug use

8.

Sensitive to perfumes, gasoline, dust, mold, pollens

9.

Been diagnosed with a chronic, or autoimmune, disease

10.

Have post-traumatic stress syndrome

11.

Decreased cognitive ability, not thinking as clearly

12.

Get shaky when angry or am under stress

13.

Chronically fatigued

14.

Need to lie down and rest frequently

15.

Can feel weak all over, "the plug gets pulled"

16.

Hard to arise in the morning and feel better after 3-4 hours

17.

History or current, asthma; reactive airway, respiratory allergies

18.

Require coffee to get the day started

19.

Crave salt

20.

Unhappy relationships affect my "joy"