AdrenalQuestionare

Adrenal Health Questionnaire: Section A
Do you frequently have low body temperatures? (<98 degrees F)	YES \| NO
Do you frequently get irritable?	YES \| NO
Do you have poor memory or concentration?	YES \| NO
Do you notice palpitations?	YES \| NO
Do you suffer from allergies or asthma?	YES \| NO
Do you bruise easily or find your wounds heal slowly?	YES \| NO
Do you frequent/chronic infections?	YES \| NO
Do you have dry, thinning skin?	YES \| NO
Do you get headaches?	YES \| NO
Do you have unexplained hair loss?	YES \| NO
Do you skip meals?	YES \| NO
Do you exercise more than one time each week?	YES \| NO
Do you have thyroid problems?	YES \| NO
Is your energy good all day?	YES \| NO
Do you need caffeine in the morning or after lunch?	YES \| NO
Are you emotionally overstressed?	YES \| NO
Do you get tenderness across your lower back?	YES \| NO
Do you suffer from depression or down moods?	YES \| NO
Do you have low blood pressure?	YES \| NO
Do you experience a "second wind" (high energy) at bedtime?	YES \| NO
Do you experience chronic or recurrent inflammation?	YES \| NO
Do you get light headed when sitting up or standing?	YES \| NO
Do you suffer from chronic pain?	YES \| NO
Do you suffer from low blood sugar/hypoglycemia? (i.e. headaches, sleepiness, mood swings if skipping meals)	YES \| NO
Do you suffer from insomnia?	YES \| NO
Do you experience symptoms of PMS? (breast tenderness, abdominal cramping, heavy periods, mood swings)	YES \| NO
Are you menopausal or peri menopausal? (skipped periods, between 44-45 yrs old, hot flashes, vaginal dryness)	YES \| NO
If your score is greater than 10, you likely have some degree of adrenal exhaustion. If your score is greater than 20, it is highly probable you have adrenal exhaustion. If your score is greater than 30, it is nearly certain you have adrenal exhaustion. Total Points: 0 - You probably do not have adrenal exhaustion. Please call our office at (949) 680-1880 to schedule an office visit or phone consultation for a personalized treatment plan that addresses your specific adrenal needs. Print your completed questionnaire and present it to your practitioner for review.