Adrenal Stress Questionnaire

This broad-screening questionnaire contains insights regarding general pituitary metabolic functions as well as various key topics associated with a variety of disorders.

The fields denoted with * are compulsory fields

* Name & Surname
* Telephone
* Email
For each statement that applies to you, enter a ' X '.

1.
Sleepy during the day, difficulty falling asleep at night
2.
Heat or cold intolerance
3.
Hot flashes, with or without sweating
4.
Failing vision: blurred, double, loss of peripheral
5.
Difficulty swallowing
6.
Heart palpitations or chest pressure sensation
7.
Skin too oily or dry
8.
General nausea (not from specific meal)
9.
Excessive thirst
10.
Mood swings
11.
Irritability
12.
Anxious
13.
Decreased enjoyment of life
14.
Difficulty concentrating, forgetful
15.
Regular use of tobacco, alcohol, recreational drugs
16.
Diminished libido (sex drive
17.
Sexual dysfunction (Women: pain, infertility. Men: premature ejaculation, erectile dysfunction, infertility)
18.
Hair loss (men and women)
19.
Weight gain, moon-like face,
20.
Increased skin pigmentation