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Adrenal Symptoms Questionnaire
for Patients

If you have read my article on fatigue and you feel that it
described you and your symptoms, you should PRINT and FILL OUT the Adrenal Symptoms Questionnaire and bring it to your first appointment with Dr. Aieta.

The Adrenal Symptoms Questionnaire is a tool for helping to diagnose adrenal gland dysfunction that patients can quickly complete. The answers to the questions help determine whether the adrenal glands are likely implicated as a factor in a person’s health concerns. The results of the questionnaire will create a picture of how the adrenal glands are functioning in terms of their response to stress. This questionnaire will aid me in determining your diagnosis and treatment.

The questionnaire is easy to complete. Simply read each statement, decide its degree of severity, and then place the appropriate number beside each statement based on the severity ranking below.

Please rank your symptom according to the categories below and enter a number from 0-3 for each question.
1=Occasionally (1-4 times per month)
2=Moderate in severity and occurs moderately in frequency
      (1-4 times per week)
3=Intense in severity and occurs frequently
     (more than 4 times per week)



Under 40: very slight or no adrenal fatigue
41-80: mild adrenal fatigue
81-120: moderate adrenal fatigue
Above 120: severe adrenal fatigue

» Click here for Dr. Aieta’s Adrenal Symptoms Questionnaire (pdf)

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Dr. Aieta is a board certified and licensed Naturopathic Physician with a private practice in West Hartford, Connecticut. He specializes in the treatment of disease, utilizing natural therapies such as acupuncture, homeopathy, spinal manipulation, clinical nutrition, and herbal medicine.



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