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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.
Check the duration box for each problem that applies.
Do you have chronic pain? Yes No Do you have chronic inflammation? Yes No
* 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.