HPA Axis Questionnaire

HPA Axis Questionnaire
Name*

First NameLast Name
Date*

MonthDayYear
Date
Please score only the items you experience on a scale of 1-4, as follows:
1 = Mild problem
2 = Significant problem
3 = Major problem
4 = Severe problem
Low Cortisol State
Lethargic Depression

1

2

3

4

1 is , 4 is
Excessive need for sleep

1

2

3

4

1 is , 4 is
Chronic Fatigue Syndrome

1

2

3

4

1 is , 4 is
Chronic Pain

1

2

3

4

1 is , 4 is
Fibromyalgia ( musculoskeletal tender points)

1

2

3

4

1 is , 4 is
Dizziness upon standing or bending

1

2

3

4

1 is , 4 is
Craving salty foods

1

2

3

4

1 is , 4 is
Fatigue

1

2

3

4

1 is , 4 is
Low blood pressure or drop in blood pressure upon standing

1

2

3

4

1 is , 4 is
Poor wound healing

1

2

3

4

1 is , 4 is
Easy bruising

1

2

3

4

1 is , 4 is
Inability to handle even the slightest stressors

1

2

3

4

1 is , 4 is
Hypoglycemia ( dizzy, irritability, or sleepy if you go without food for a few hours, relieved by eating food )

1

2

3

4

1 is , 4 is
Unusually dark scars, elbows, nipples, or skin near the nails

1

2

3

4

1 is , 4 is
Unstable body temperatures (hot or cold )

1

2

3

4

1 is , 4 is
High Cortisol State
Agitated Depression

1

2

3

4

1 is , 4 is
Stretch marks that are not from weight loss

1

2

3

4

1 is , 4 is
Weight gain around the abdomen, back of the neck, or face and cheeks

1

2

3

4

1 is , 4 is
Adult Onset Diabetes

1

2

3

4

1 is , 4 is
Osteoporosis

1

2

3

4

1 is , 4 is
Sweet Cravings

1

2

3

4

1 is , 4 is
Trouble falling asleep or staying asleep

1

2

3

4

1 is , 4 is
Adrenal Hyperplasia
Excessive dark male pattern hair growth (Women)

1

2

3

4

1 is , 4 is
Irregular or no menstrual cycles ( not in menopause)

1

2

3

4

1 is , 4 is
Eastern European heritage

1

2

3

4

1 is , 4 is
Scoring
There is no absolute cut off. There is a continuum between normal and dysfunction. This scoring is best used in conjunction with blood testing or salivary cortisol testing.
Low cortisol state:      /64 =
Elevated cortisol state:      /28 =
Adrenal hyperplasia:      /12 =
Should be Empty:

HPA Axis Questionnaire

Low Cortisol State

High Cortisol State

Adrenal Hyperplasia

Scoring