HPA Axis Questionnaire

Table of contents:

HPA AXIS Questionnaire
Please score only the items you experience on a scale of 1-4:
1 (This is a mild problem)
2 (This is a significant problem)
3 (This is a major problem)
4 (This is a 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)
17. Agitated Depression
18. Weight gain around your abdomen, back of neck, and in the face and cheeks*
19. Stretch marks-not from weight loss *
20. Adult onset diabetes
21. Osteoporosis
22. Craving sweets
23. Trouble falling or staying asleep
24. Excessive dark male pattern hair growth (women)*
25. Irregular or no periods (not menopausal)
26. Eastern European heritage

HPA Axis Questionnaire: Practitioner Interpretive Key
The goal of this intake sheet is to obtain and collate data that will give you an idea of the presence and type of HPA axis dysfunction in your patient. These symptoms and signs are primarily a compilation from the Williams Textbook of Endocrinology-11th edition, as well as recent literature, and lastly, clinical experience. There are three sections divided by lines. Section 1 is correlated with low cortisol states, section 2 with high cortisol states, and section 3 with adrenal hyperplasia. Items with an asterisk should be assessed by physical examination.
Add up the patient

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