Adrenal_stress_questionnaire

Adrenal Stress Assessment
Stress Test Evaluation

This questionnaire is a subjective assessment of stressors and related symptoms and complaints. The questions have assigned scores/point values. The information will be transmitted to Dr. Saks for evaluation and results will be reviewed at your next office visit. Read more about the Adrenal Stress Index, salivary testing >>

Welcome Guest,

Patient Wellness Questionnaire

Patient Name:		*^{ (Required Field)}**
eMail Address:		*^{ (Required Field)}**

Part A

Adrenal Related Problems	For the past:
Excessive Fatigue
Dry & Thin Skin
Nervous/Irritability
Low Body Temperature
Premenstrual Tension
Inability to Concentrate
Mental Depression
Food Allergies/Sensitivities
Craving for Sweets
Headaches
Alcohol Intolerance
Poor Memory
Heart Palpitations

Part B

Do you have chronic pain
Do you have chronic inflammation

Part C

Have you experienced any of these in the past 12 months?
Death of a spouse
Divorce
Marital separation
Jail term
Death of a close family member
Personal injury or illness
Marriage
Fired from work
Marriage reconciliation
Retirement
Change in family members health
Pregnancy
Sex difficulties
Addition to family
Business readjustment
Change in financial status
Death of a close friend
Change in line of work
Change in # of marital arguments
Mortgage or loan over $10,000
Foreclosure of mortgage or loan
Change in work responsibilities
Son or daughter leaving home
Trouble with in-laws
Outstanding achievement
Spouse begins or stops work
Start or finishing school
Change in living conditions
Revision of personal habits
Trouble with boss
Change in work hours or conditions
Change in residence
Change in schools
Change in recreational habits
Mortgage or loan under $10,000
Change in sleeping habits
Change in eating habits
Vacation

Disclaimer:
The information contained in this eMail is for information and educational purposes only. This information is not intended to diagnose or treat any illness or diseases. Before undertaking any health regimen, please consult with your own health care provider. Only a licensed health professional can diagnose and treat disease. If your health care needs personal attention, you are welcome to become a telephone consulting client.

By submitting this form you attest that you have read this disclaimer.

Adrenal Stress Assessment Stress Test Evaluation

Adrenal Stress Assessment
Stress Test Evaluation