HPA Axis Questionnaire

Date

Name

First NameLast Name

Date

Email

example@example.com

Low cortisol state

Section 1 Score: {section112}

Divided by 64 = {section119}

Elevated cortisol state

Section 2 Score: {section213}

Divided by 28 = {section217}

Adrenal hyperplasia

Section 3 Score: {section314}

Divided by 12 = {section318}

The hypothalamus, pituitary, adrenal (HPA) axis is the body’s central stress
response system. This questionnaire is designed to help assess and differentiate
possible dysfunction within this system. Please score the items below you experience from no problem to a severe problem. Items with an asterisk (*) should be assessed by physical exam.

Section 1: Low Cortisol State

	No Problem	Mild Problem	Significant Problem	Major Problem	Severe Problem
1. Lethargic depression
2. Excessive need for sleep
3. Chronic fatigue syndrome
4. Chronic pain
5. Fibromyalgia (musculoskeletal tender points)*
6. Dizziness when you stand or bend
7. Low blood pressure and/or drop of blood pressure on standing*
8. Craving salty foods (pretzels, pickles, etc.)
9. Poor wound healing*
10. Easy bruising
11.Fatigue
12. Inability to handle even slight stresses
13. Hypoglycemia: dizzy, irritable, or sleepy if you go without food for 4-5 hours; symptoms relieved by food
14. Scars, elbows, nipples, or skin near nails that are unusually dark*
15. Slow healing of cuts*
16. Unstable body temperatures (hot or cold)

Section 1 Calculation

Section 1 Low cortisol state score

Section 2: Elevated Cortisol State

	No Problem	Mild Problem	Significant Problem	Major Problem	Severe Problem
17. Agitated depression
18. Weight gain around your abdomen, back of neck, and in the face and cheeks*
19. Stretch marks that are not from weight loss*
20. Adult-onset diabetes
21. Osteoporosis
22. Craving sweets
23. Trouble falling asleep or staying asleep

Section 2 Calculation

Section 2 Low cortisol state score

Section 3: Adrenal Hyperplasia

	No Problem	Mild Problem	Significant Problem	Major Problem	Severe Problem
24. Excessive dark male pattern hair growth (women)*
25. Irregular or no periods (not menopausal)
26. Eastern European heritage

Section 3 Calculation

Section 3 Adrenal hyperplasia state score

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