A Graceful Touch  /  Physician's Touch - 248 687 4465  Holistic Health Care, Massage & Spa Services
ADRENAL STRESS QUESTIONNAIRE
 
 
____Morning fatigue-you don’t really seem to “wake up” until 10am, even if you’ve been awake since 7am and / or the need for caffeine to wake up
 
____Afternoon “low” (feelings of sleepiness or clouded thinking) from 2 to 4 pm and the need for caffeine for that energy boost
 
____Burst of energy at 6pm—you finally feel better after your afternoon lull with or out with out caffeine
 
____Sleepiness at 9 to 10 pm---However you resist sleep or van not    sleep  and / or waking up ½ way through the night and/ or can not go back to sleep for a period of time more the 15 – 30 minutes
 
____Craving for foods high in salts, sweets / sugars, carbohydrates and fats epically ay night
 
____Mild depression to severe depression. Thinking you might need Rx Anti-depressants prescribed from an M.D.
 
____Lack of energy, listlessness dull spirits, lacking in humor ability, lack of enthusiasm in those issues what were before enthusiastic for you
 
____Decreased ability to handle stress, collapse / shut down at when 1 or more stress issues preset themselves.   
 
____Muscular weakness, muscle exhaustion where normally there was neither weakness nor tiredness
 
____Increased allergies, itchy eyes, runny nose, itchy inner ears, itchy, irritated, scratchy throat.
 
____Lightheadednes or weakness when getting up from a sitting or laying down position
____Decreased sex drive, dehydration or vaginal fluids, reproductive issues, monthly cycle etc
 
____Frequent sighing, needing to rest, need to take more breaks and more frequently than before.
 
____ Mental Fog, memory lapses, mental confusion
 
____ Digestion Dysfunction, indigestion, acid reflux, constipation, diarrhea, etc
 

Date ________
1-4 stage  one, 
5—9 stage two
10-14 stage three  

If you want more information or want to have a conversation about your questionnaire results you can contact Dr. Kathryn Knox 

info@atouchofgrace.info

or call directly 248 545 3222
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