HPA Axis Questionnaire

Full Name

Date Picker

The hypothalamus, pituitary, adrenal (HPA) axis is the body’s central stress response system. This questionnaire is designed to help assess and differentiate possible dysfunction within this system.

Instructions Please score only the items you experience on a scale of 1 to 4, as follows: 1 = mild problem 2 = significant problem 3 = major problem 4 = severe problem

Section 1: Low Cortisol State

Lethargic depression
Excessive need for sleep
Chronic fatigue syndrome
Chronic pain
Fibromyalgia (musculoskeletal tender points)
Dizziness when you stand or bend
Low blood pressure and/or drop of blood pressure on standing
Craving salty foods (pretzels, pickles, etc.)
Poor wound healing
Easy bruising
Fatigue
Inability to handle even slight stresses
Hypoglycemia: dizzy, irritable, or sleepy if you go without food for 4-5 hours; symptoms relieved by food
Scars, elbows, nipples, or skin near nails that are unusually dark
Slow healing of cuts
Unstable body temperatures (hot or cold)

Section 2: Elevated Cortisol State

Agitated depression
Weight gain around your abdomen, back of neck, and in the face and cheeks
Stretch marks that are not from weight loss
Adult-onset diabetes
Osteoporosis
Craving sweets
Trouble falling asleep or staying asleep

Section 3: Adrenal Hyperplasia

Excessive dark male pattern hair growth (women)
Irregular or no periods (not menopausal)
Eastern European heritage

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. The symptoms are divided into three sections, as follows:

• Section 1 is correlated with low cortisol states

• Section 2 is correlated with high cortisol states

• Section 3 is correlated with adrenal hyperplasia

The items on the questionnaire marked with an asterisk (*) should be assessed by physical examination. Practitioner Instructions for Scoring Add up the patient’s totals for each section.

Enter them below over the highest possible score for each section and divide. The results will indicate which areas to focus on. There is no absolute cutoff to use; rather, there is a continuum between normal and dysfunction.

Use this information in conjunction with blood testing and salivary cortisol testing.

• Section 1 — Low cortisol state: /64 =

• Section 2 — Elevated cortisol state: /28 =

• Section 3 — Adrenal hyperplasia: /12 =