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Stress Test Evaluation for the Adrenal Stress Index™ (ASI™)

1. This questionnaire is a subjective assessment of stressors and related symptoms and complaints. The questions have assigned scores/point values. Fill up the form and make a printout to give to your doctor for evaluation.

2. If you score moderate to high on Part A, answer yes once in Part B, and score 151 or more on Part C, the Adrenal Stress Index test may be required.

Part A - Adrenal Related Problems

Check the duration box for each problem that applies.

Adrenal Related ProblemsDuration (Years)
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 palipitations                

Part B - Chronic Conditions

Do you have chronic pain?
Do you have chronic inflammation?

Part C - Social Readjustment Rating Scale*

* Holmes, TH and Rahe, RH Booklet for Schedule of Recent Experience (SRE) Seattle, University of Washington, 1967

Check the box of each life event in this list that happened in the last twelve months.

Life EventSelect
Death of spouse
Divorce
Marital separation
Jail term
Death of close family member
Personal injury or illness
Marriage
Fired from work
Marital reconciliation
Retirement
Change in family member's health
Pregnancy
Sex difficulties
Addition to family
Business readjustment
Change in financial status
Death of close friend
Change in line of work
Change in # of marital arguments
Mortgage or loan over $10K
Foreclosure of mortgage or loan
Change in work responsibilities
Son or daughter leaving home
Trouble with in-laws
Outstanding personal achievement
Spouse begins or stops work
Starting or finishing school
Change in living conditions
Revision of personal habits
Trouble with boss
Change in work hours and/or conditions
Change in residence
Change in schools
Change in recreational habits
Mortgage or loan under $10K
Change in sleeping habits
Change in eating habits
Vacation

Results