Stress
Test Evaluation for Adrenal Stress Index (ASI)
_________________________________________________________
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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. Add the scores of each
section 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, Adrenal Stress Index test may be required.
Part A
To obtain score, multiply points (column 1) by duration (column 2).
|
Adrenal Related
Problems |
Duration (Years) |
Score |
| Excessive
Fatigue |
10 |
x |
1/2 |
1 |
2 |
________ |
| Dry
& Thin Skin |
10 |
x |
1/2 |
1 |
2 |
________ |
| Nervous/Irritability |
9 |
x |
1/2 |
1 |
2 |
________ |
| Low
body temperature |
8 |
x |
1/2 |
1 |
2 |
________ |
| Premenstrual
tension |
8 |
x |
1/2 |
1 |
2 |
________ |
| Inability
to concentrate |
x8 |
x |
1/2 |
1 |
2 |
________ |
| Mental
depression |
8 |
x |
1/2 |
1 |
2 |
________ |
| Food
allergies
& sensitivities |
7 |
x |
1/2 |
1 |
2 |
________ |
| Craving
for sweets |
7 |
x |
1/2 |
1 |
2 |
________ |
| Headaches |
6 |
x |
1/2 |
1 |
2 |
________ |
| Alcohol
intolerance |
6 |
x |
1/2 |
1 |
2 |
________ |
| Poor
memory |
5 |
x |
1/2 |
1 |
2 |
________ |
| Heart
palipitations |
5 |
x |
1/2 |
1 |
2 |
________ |
Total Score |
|
|
|
|
|
________ |
30
or less: Minimal probability of Adrenal Axis-Stress related problem.
31 to 50: xModerate probability of Adrenal Axis-Stress related problem.
ASI Test worth consideration.
51 and up: High probability of Adrenal Axis-Stress related problem.
ASI Test recommended.
Part
B
Do you have chronic pain: o Yes o No
Do
you have chronic inflammation: o Yes o No
Part
C
Social Readjustment Rating Scale*
Circle YES or NO to each life event in this list that happened in the
last twelve months. For every "Yes" that applies, give yourself
the points as listed. Upon completion, total the score and enter in box
below.
| LIFE
EVENT |
ANSWER |
POINTS |
| |
|
|
| Death
of spouse |
Yesxx
No |
100 |
| Divorce |
Yesxx
No |
73 |
| Marital
seperation |
Yes
xxNo |
65 |
| Jail
term |
Yes
xxNo |
63 |
| Death
of close family member |
Yes
xxNo |
63 |
| Personal
injury or illness |
Yesxx
No |
53 |
| Marriage |
Yesxx
No |
50 |
| Fired
from work |
Yesxx
No |
47 |
| Marital
reconciliation |
Yes
xxNo |
45 |
| Retirement |
Yes
xxNo |
45 |
| Change
in family members health |
Yes
xxNo |
44 |
| Pregnancy |
Yes
xxNo |
40 |
| Sex
difficulties |
Yes
xxNo |
39 |
| Addition
to family |
Yesxx
No |
39 |
| Business
readjustment |
Yes
xxNo |
39 |
| Change
in financial status |
Yes
xxNo |
38 |
| Death
of close friend |
Yesxx
No |
37 |
| Change
in line of work |
Yes
xxNo |
36 |
| Change
in # of marital arguements |
Yesxx
No |
35 |
| Mortgage
or loan over $10,000 |
Yes
xxNo |
31 |
| Foreclosure
of mortgage or loan |
Yes
xxNo |
30 |
| Change
in work responsibilities |
Yesxx
No |
29 |
| Son
or daughter leaving home |
Yesxx
No |
29 |
| Trouble
with in-laws |
Yes
xxNo |
29 |
| Outstanding
personal achievement |
Yesxx
No |
28 |
| Spouse
begins or stops work |
Yes
xxNo |
26 |
| Starting
or finishing school |
Yes
xxNo |
26 |
| Change
in living conditions |
Yes
xxNo |
25 |
| Revision
of personal habits |
Yes
xxNo |
24 |
| Trouble
with boss |
Yes
xxNo |
23 |
| Change
in work hours, conditions |
Yesxx
No |
20 |
| Change
in residence |
Yesxx
No |
20 |
| Change
in schools |
Yesxx
No |
20 |
| Change
in recreational habits |
Yesxx
No |
19 |
| Mortgage
or loan under $10,000 |
Yes
xxNo |
18 |
| Change
in sleeping habits |
Yesxx
No |
16 |
| Change
in eating habits |
Yesxx
No |
15 |
| Vacation |
Yesxx
No |
13 |
POINTS
TOTAL
_________________________________________________________
150 or less 37% chance of illness within the next two years.
151 - 299 50% chance of illness within the next two years. ASI test worth
consideration.
300 or above 80% chance of illness within the next two years. ASI test
recommended.
If
you scored Moderate to High on Part A, answered yes once in Part B, and
scored 151 or more on Part C, the Adrenal Stress Index test is highly
advised.
*
Holmes, TH and Rahe, RH Booklet for Schedule of Recent Experience (SRE)
Seattle, University of Washington, 1967
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