Clinic Hours

Tuesday    9:30am – 2:00pm
Thursday  9:30am – 7:00pm
Online Mon 11am-8pm • Wed 11am-8pm
** After hours appointments available

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03 5977 2000
heallth@nicoletopp.com.au

Clinic suite located at Chiropractic Connection
5  St. Catherines Ct, Mornington, Victoria 3931

 

In Clinic Tues: 9:30am - 2pm & Thur: 9:30am - 7pm

03 5977 2000

5 St. Catherines Ct, Mornington, Victoria 3931

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Adrenal Fatigue Questionnaire - Nicole Topp - Naturopath
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Instructions: Please enter the appropriate response number to each statement below.


Predisposing Factors

0 = Never/Rarely ---- 1 = Occasionally/Slightly ---- 2 = Moderate in Intensity or Frequency ---- 3 = Intense/Severe or Frequent

*
Key Signs & Symptoms

0 = Never/Rarely ---- 1 = Occasionally/Slightly ---- 2 = Moderate in Intensity or Frequency ---- 3 = Intense/Severe or Frequent

*
Energy Patterns
0 = Never/Rarely ---- 1 = Occasionally/Slightly ---- 2 = Moderate in Intensity or Frequency ---- 3 = Intense/Severe or Frequent
*
Frequently Observed Events
0 = Never/Rarely ---- 1 = Occasionally/Slightly ---- 2 = Moderate in Intensity or Frequency ---- 3 = Intense/Severe or Frequent
*
Food Patterns
0 = Never/Rarely ---- 1 = Occasionally/Slightly ---- 2 = Moderate in Intensity or Frequency ---- 3 = Intense/Severe or Frequent
*
Aggravating Patterns
0 = Never/Rarely ---- 1 = Occasionally/Slightly ---- 2 = Moderate in Intensity or Frequency ---- 3 = Intense/Severe or Frequent
*
This questionnaire was originally created and used by Dr. James L. Wilson in his practice and later published on page 61 in his book, Adrenal Fatigue: The 21st Century Stress Syndrome. The author’s permission has been given to healthcare professionals to use this questionnaire in their practices. It is designed as an aid todetermining a patient’s level of adrenal fatigue. Although Dr. Wilson and many other physicians have found the questionnaire extremely helpful, no formal reliability or validity tests have been completed to confirm its accuracy, and the author assumes no responsibility for its use or accuracy. No commercial use of this questionnaire is permitted without prior written consent by the author.