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In-depth Questionnaire

   

In-depth 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.

For each yes answer in Section A, circle the Point Score. Total your score, and record it at the end of the section. Then move on to Sections B and C, and score as directed.

Section A: History Point Score

Questionnaire

Point score

1. Have you taken tetracyclines (Sumycin(r), Panmycin(r), Vibramycin(r), Minocin(r), etc.) or other antibiotics for acne for 1 month (or longer)?

50

2. 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?

50

3. Have you taken a broad spectrum antibiotic drug - even for one period?

6

4. Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your reproductive organs?

25

5. Have you been pregnant 2 or more times?

Pregnant 1 time?

5

3

6. Have you taken birth control pills for more than 2 years?

Take birth control pills 6 months to 2 years?

15

8

7. Have you taken prednisone, Decadron(r), or other cortisone-type drugs by mouth or inhalation ** for more than 2 weeks?

Taken these drugs 2 weeks or less?

15
 

6

8. Does exposure to perfumes, insecticides, fabric shop odors, or other chemicals provoke moderate to severe symptoms?

Does exposure produce mild symptoms?

20
 

5

9. Are your symptoms worse on damp, muggy days or in moldy places?

20

10. 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?

 Mild or moderate?

20
 

10

11. Do you crave sugar?

10

12. Do you crave breads?

10

13. Do you crave alcoholic beverages?

10

14. Does tobacco smoke really bother you?

10

Total Score, Section A __________________________________________

** The use of nasal or bronchial sprays cortisone and/or other steroids promotes overgrowth in the respiratory tract.

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