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This questionnaire is designed for adults and the scoring system isn't appropriate for children. Scores in women will run higher, as seven symptoms/conditions apply exclusively to women, while only 2 apply exclusively to men.

In SECTION A it lists factors in your medical history which promote the growth of Candida alibicans. SECTIONS B and C deal with symptoms commonly found in individuals with a yeast-connected illness.

Please answer every question in each section. Then move on to each section and submit only if all questions have been answered.

Completing this questionnaire and receiveing your results should help you and your health professional evaluate the possible role of Candida in contributing to your health problem. Yet it will not provide an automatic "Yes" or "No" answer.

SECTION A: HISTORY
  • Have you taken tetracyclines or other antibiotics for acne for 2 months or longer?
YES NO
  • Have you, at any time in your life, taken other "broad spectrum" antibiotics* for repiratory, urinary or other infections? This means for 2 months or longer, or as in shorter courses of 4 or more times in a 1 year period. (*Includes: Keflex, Ampicillin, Amoxicillian, Ceclor, bactrim and Septra)
YES NO
  • Have you, at any time in your life, been troubled by persistent vaginal problems or had 3 or more episodes of vaginitis in a year?
YES NO
  • Have you ever been pregnant?
No
Once
More
  • Have you taken birth control pills?
No
6-24 months
More than 2 yrs.
  • Have you taken prednisone, Decadron (R) or other cortisone-type drugs?
No
2 weeks or less
2 weeks or more
  • Does exposure to perfumes, insecticides, fabric shop oders and other chemicals provoke symptoms?
None
Mild
Moderate/Severe
  • Are your symptoms worse on damp, muggy days or in moldy places?
YES NO
  • Have you had persistent athlete's foot, "jock itch" or other chronic fungous infections of the skin or nails? Have such infections been persistent or moderate?
None
Mild
Severe
  • Do you crave sugar?
YES NO
  • Do you crave breads?
YES NO
  • Do you crave alcoholic beverages?
YES NO
  • Does tobacco smoke REALLY bother you?
YES NO
SECTION B: MAJOR SYMPTOMS

For each symptom which follows, choose "mild" if the symptom occurs occasionally, "moderate" if the symptom occurs frequently, and "severe" if the symptom is persistent and/or disabling.

  • Fatigue or Lethargy
None Mild Moderate Severe
  • Feeling of being "drained"
None Mild Moderate Severe
  • Poor Memory
None Mild Moderate Severe
  • Feeling "spacey" or "unreal"
None Mild Moderate Severe
  • Depression
None Mild Moderate Severe
  • Numbness, burning or tingling
None Mild Moderate Severe
  • Muscle aches
None Mild Moderate Severe
  • Muscle weakness or paralysis
None Mild Moderate Severe
  • Pain and or swelling joints
None Mild Moderate Severe
  • Abdominal pain
None Mild Moderate Severe
  • Constipation
None Mild Moderate Severe
  • Diarrhea
None Mild Moderate Severe
  • Bloating
None Mild Moderate Severe
  • Troublesome vaginal discharge
None Mild Moderate Severe
  • Persistent vaginal burning or itching
None Mild Moderate Severe
  • Prostatitis
None Mild Moderate Severe
  • Impotence
None Mild Moderate Severe
  • Loss of sexual feelings
None Mild Moderate Severe
  • Endometriosis
None Mild Moderate Severe
  • Dysmenorrhea
None Mild Moderate Severe
  • Premenstrual tension
None Mild Moderate Severe
  • Spots in front of eyes
None Mild Moderate Severe
  • Erratic vision
None Mild Moderate Severe
SECTION C: OTHER SYMPTOMS

While the symptoms in this section occur commonly in patients with yeast-connected illness, it should be noted that they also occur in individuals who do not have Candida. For each symptom which follows, choose "mild" if the symptom occurs occasionally, "moderate" if the symptom occurs frequently, and "severe" if the symptom is persistent and/or disabling.

  • Drowsiness
None Mild Moderate Severe
  • Irritability or jitteriness
None Mild Moderate Severe
  • Lack of coordination
None Mild Moderate Severe
  • Frequent mood swings
None Mild Moderate Severe
  • Headache
None Mild Moderate Severe
  • Dizziness / loss of balance
None Mild Moderate Severe
  • Pressure above ears/feeling of head swelling and tingling
None Mild Moderate Severe
  • Inability to concentrate or insomnia
None Mild Moderate Severe
  • Rectal itching
None Mild Moderate Severe
  • Hives, Eczema, other rashes
None Mild Moderate Severe
  • Heartburn
None Mild Moderate Severe
  • Indigestion
None Mild Moderate Severe
  • Belching and intestinal gas
None Mild Moderate Severe
  • Mucus in stools
None Mild Moderate Severe
  • Hemorrhoids
None Mild Moderate Severe
  • Dry mouth
None Mild Moderate Severe
  • Mouth rashes, blisters, white tongue
None Mild Moderate Severe
  • Bad breath
None Mild Moderate Severe
  • Joint swelling or arthritis
None Mild Moderate Severe
  • Nasal congestion or discharge
None Mild Moderate Severe
  • Postnasal drip
None Mild Moderate Severe
  • Nasal itching
None Mild Moderate Severe
  • Sore or dry throat
None Mild Moderate Severe
  • Cough
None Mild Moderate Severe
  • Pain or tightness in chest
None Mild Moderate Severe
  • Wheezing or shortness of breath
None Mild Moderate Severe
  • Urgency or urinary frequency
None Mild Moderate Severe
  • Burning on urination
None Mild Moderate Severe
  • Failing vision
None Mild Moderate Severe
  • Burning, itching or tearing of eyes
None Mild Moderate Severe
  • Recurrent ear infections
None Mild Moderate Severe
  • Fluid in ears
None Mild Moderate Severe
  • Ear pain or deafness
None Mild Moderate Severe
  • Sensitivty to milk, wheat, corn or other common foods
None Mild Moderate Severe
  • Other symptoms
None Mild Moderate Severe
clear the whole form







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