Yeast Questionnaire

This questionnaire lists factors in your medical history that promote the growth of the common yeast, Candida albicans (Section A), and symptoms commonly found in individuals with yeast-connected illness (Sections B and C).

* Filling out and scoring this questionnaire should help you and your physician evaluate how Candida albicans may be contributing to your health problems. Yet it will not provide an automatic Yes or No answer. A comprehensive history and physical examination are important. In addition, laboratory studies, x-rays, and other types of tests may also be appropriate.

Section A: History

Answer Yes or No by clicking in the circle beside your answer.
Have you taken antibiotics for acne for 1 month (or longer)?
(Point score - 50)
Yes No
Have you, at any time in your life, taken other "broad spectrum" antibiotics for respiratory, urinary or other infections for 2 months or longer, or for shorter periods 4 or more times in a 1-year span?
(Point score - 50)
Yes No
Have you taken a broad spectrum antibiotic drug – even for one period?
(Point score - 6)
Yes No
Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your reproductive organs?
(Point score - 25)
Yes No
Have you been pregnant 2 or more times?
(Point score - 5)
Yes No
Pregnant 1 time?
(Point score - 3)
Yes No
Have you taken birth control pills for more than 2 years?
(Point score - 15)
Yes No
Taken birth control pills 6 months to 2 years?
(Point score - 8)
Yes No
Have you taken cortisone-type drugs by mouth or inhalation for more than 2 weeks?
(Point score - 15)
Yes No
Taken these drugs 2 weeks or less?
(Point score - 6)
Yes No
Does exposure to perfumes, insecticides, fabric shop odors, or other chemicals provoke moderate to severe symptoms?
(Point score - 20)
Yes No
Does exposure produce mild symptoms?
(Point score - 5)
Yes No
Are your symptoms worse on damp, muggy days or in moldy places?
(Point score - 20)
Yes No
Have you had athlete’s foot, ringworm, "jock itch" or other chronic fungus infections of the skin or nails that have been severe or persistent?
(Point score - 20)
Yes No
Mild or moderate?
(Point score - 10)
Yes No
Do you crave sugar?
(Point score - 10)
Yes No
Do you crave breads?
(Point score - 10)
Yes No
Do you crave alcoholic beverages?
(Point score - 10)
Yes No
Does tobacco smoke really bother you?
(Point score - 10)
Yes No

Section B: Major Symptoms

Click in the circle beside your answer. If you haven't experienced any of the symptoms stated in the question, leave it blank. If a symptom is occasional or mild, score 3 points. If a symptom is frequent and/or moderately severe, score 6 points. If a symptom is severe and/or disabling, score 9 points.
Fatigue or lethargy Occasional/Mild
Frequent/Moderate
Severe/Disabling
Feeling of being "drained" Occasional/Mild
Frequent/Moderate
Severe/Disabling
Poor memory Occasional/Mild
Frequent/Moderate
Severe/Disabling
Feeling "spacey" or "unreal" Occasional/Mild
Frequent/Moderate
Severe/Disabling
Inability to make decisions Occasional/Mild
Frequent/Moderate
Severe/Disabling
Numbness, burning or tingling Occasional/Mild
Frequent/Moderate
Severe/Disabling
Insomnia Occasional/Mild
Frequent/Moderate
Severe/Disabling
Muscle aches Occasional/Mild
Frequent/Moderate
Severe/Disabling
Muscle weakness or paralysis Occasional/Mild
Frequent/Moderate
Severe/Disabling
Pain and/or swelling in joints Occasional/Mild
Frequent/Moderate
Severe/Disabling
Abdominal pain Occasional/Mild
Frequent/Moderate
Severe/Disabling
Constipation Occasional/Mild
Frequent/Moderate
Severe/Disabling
Diarrhea Occasional/Mild
Frequent/Moderate
Severe/Disabling
Bloating, belching or intestinal gas Occasional/Mild
Frequent/Moderate
Severe/Disabling
Troublesome vaginal burning, itching or discharge Occasional/Mild
Frequent/Moderate
Severe/Disabling
Prostatitis Occasional/Mild
Frequent/Moderate
Severe/Disabling
Impotence Occasional/Mild
Frequent/Moderate
Severe/Disabling
Loss of sexual desire or feeling Occasional/Mild
Frequent/Moderate
Severe/Disabling
Endometriosis or infertility Occasional/Mild
Frequent/Moderate
Severe/Disabling
Cramps and/or other menstrual irregularities Occasional/Mild
Frequent/Moderate
Severe/Disabling
Premenstrual tension Occasional/Mild
Frequent/Moderate
Severe/Disabling
Attacks of anxiety or crying Occasional/Mild
Frequent/Moderate
Severe/Disabling
Cold hands or feet and/or chilliness Occasional/Mild
Frequent/Moderate
Severe/Disabling
Shaking or irritable when hungry Occasional/Mild
Frequent/Moderate
Severe/Disabling

Section C: Other Symptoms

Click in the circle beside your answer. If you haven't experienced any of the symptoms stated in the question, leave it blank. If a symptom is occasional or mild, score 3 points. If a symptom is frequent and/or moderately severe, score 6 points. If a symptom is severe and/or disabling, score 9 points.
Drowsiness Occasional/Mild
Frequent/Moderate
Severe/Disabling
Irritability or jitteryness Occasional/Mild
Frequent/Moderate
Severe/Disabling
Incoordination Occasional/Mild
Frequent/Moderate
Severe/Disabling
Inability to concentrate Occasional/Mild
Frequent/Moderate
Severe/Disabling
Frequent mood swings Occasional/Mild
Frequent/Moderate
Severe/Disabling
Headaches Occasional/Mild
Frequent/Moderate
Severe/Disabling
Dizziness/loss of balance Occasional/Mild
Frequent/Moderate
Severe/Disabling
Pressure above ears, feeling of head swelling Occasional/Mild
Frequent/Moderate
Severe/Disabling
Tendency to bruise easily Occasional/Mild
Frequent/Moderate
Severe/Disabling
Chronic rashes or itching Occasional/Mild
Frequent/Moderate
Severe/Disabling
Psoriasis or recurrent hives Occasional/Mild
Frequent/Moderate
Severe/Disabling
Indigestion or heartburn Occasional/Mild
Frequent/Moderate
Severe/Disabling
Food sensitivity or intolerance Occasional/Mild
Frequent/Moderate
Severe/Disabling
Mucus in stools Occasional/Mild
Frequent/Moderate
Severe/Disabling
Rectal itching Occasional/Mild
Frequent/Moderate
Severe/Disabling
Dry mouth or throat Occasional/Mild
Frequent/Moderate
Severe/Disabling
Rash or blisters in mouth Occasional/Mild
Frequent/Moderate
Severe/Disabling
Bad breath Occasional/Mild
Frequent/Moderate
Severe/Disabling
Foot, hair or body odor not relieved by washing Occasional/Mild
Frequent/Moderate
Severe/Disabling
Nasal congestion or post nasal drip Occasional/Mild
Frequent/Moderate
Severe/Disabling
Nasal itching Occasional/Mild
Frequent/Moderate
Severe/Disabling
Sore throat Occasional/Mild
Frequent/Moderate
Severe/Disabling
Laryngitis, loss of voice Occasional/Mild
Frequent/Moderate
Severe/Disabling
Cough or recurrent bronchitis Occasional/Mild
Frequent/Moderate
Severe/Disabling
Pain or tightness in chest Occasional/Mild
Frequent/Moderate
Severe/Disabling
Wheezing or shortness of breath Occasional/Mild
Frequent/Moderate
Severe/Disabling
Urinary frequency, urgency or incontinence Occasional/Mild
Frequent/Moderate
Severe/Disabling
Burning on urination Occasional/Mild
Frequent/Moderate
Severe/Disabling
Spots in front of eyes or erratic vision Occasional/Mild
Frequent/Moderate
Severe/Disabling
Burning or tearing of eyes Occasional/Mild
Frequent/Moderate
Severe/Disabling
Recurrent infections or fluid in ears Occasional/Mild
Frequent/Moderate
Severe/Disabling
Ear pain or deafness Occasional/Mild
Frequent/Moderate
Severe/Disabling

Section D: Gender

Answer Yes or No by clicking in the circle beside your answer.
Are you male or female? M     F
Your Score:
Results:

The total score will help you and your physician decide if your health problems are yeast-connected. Scores for women will run higher, as 7 items in this questionnaire apply exclusively to women, while only 2 apply exclusively to men.

Yeast-connected health problems are almost certainly present in women with scores over 180, and in men with scores over 140.

Yeast-connected health problems are probably present in women with scores over 120, and in men with scores over 90.

Yeast-connected health problems are possibly present in women with scores over 60, and in men with scores over 40.

With scores less than 60 for women and 40 for men, yeast are less apt to cause health problems.

 

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