Adrenal Stress Questionnaire

Adrenal stress questionnaire has been designed specifically to identify symptoms related to adrenal exhaustion, which is considered by medical professionals as one of the most under-diagnosed and obscure illnesses. Adrenal stress leads to adrenal fatigue, which occurs due to dysfunctional adrenal glands and this may ultimately lead to a drop in the production of adrenal hormones in the body affecting or impacting the physiology of a person seriously. The adrenal stress questionnaire attempts to answer certain questions so that medical professionals can handle the situation better.

Sample Adrenal Stress Questionnaire:

Name of the Patient: _____________________________

Name of the Doctor: _____________________________

Last visit to physician: _______________ (MM/DD/YY)

Address: ______________________________________  City:_______________

State: __________________  Zip: ________________

Email: _____________________________

Phone Number: ____________________________

  • Is it true that you experience sleeping problems like insomnia or sleep apnea?

a)      Very true

b)      Somewhat true

c)      Untrue

d)     Don’t know

  • Do you feel a surge of high energy in the night?

a)      Yes

b)      No

c)      Don’t Know

  • Do you suffer from high and low energy levels throughout the day?

a)      Yes

b)      No

c)      Don’t Know

  • Which of the following is lacking, subdued or completely missing in your life?

a)      High libido

b)      Consistent work performance

c)      Great inter-personal communication at work

d)     Good personal relationships

e)      Great family life

  • Which of the following symptoms are quite common or frequent?

a)      Bouts of depression

b)      Tiredness or fatigue

c)      Shy away from sports

d)     Laziness

e)      Lack of motivation

f)       Skipping meals or lack of appetite

g)      Lack of interest

  • Do you get irritated or angry easily?

a)      Yes

b)      No

c)      Don’t Know

  • Do you suffer from frequent headaches or muscle aches?

a)      Yes

b)      No

c)      Don’t Know

Category: Stress Questionnaire

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