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
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Questionnaire
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Point score
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1. Have you taken tetracyclines (Sumycin(r), Panmycin(r),
Vibramycin(r), Minocin(r), etc.) or other antibiotics for
acne for 1 month (or longer)?
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50
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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?
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50
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3. Have you taken a broad spectrum antibiotic drug - even
for one period?
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6
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4. Have you, at any time in your life, been bothered by persistent
prostatitis, vaginitis, or other problems affecting your reproductive
organs?
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25
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5. Have you been pregnant 2 or more times?
Pregnant 1 time?
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5
3
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6. Have you taken birth control pills for more than 2 years?
Take birth control pills 6 months to 2 years?
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15
8
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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?
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15
6
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8. Does exposure to perfumes, insecticides, fabric shop odors,
or other chemicals provoke moderate to severe symptoms?
Does exposure produce mild symptoms?
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20
5
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9. Are your symptoms worse on damp, muggy days or in moldy
places?
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20
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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?
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20
10
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11. Do you crave sugar?
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10
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12. Do you crave breads?
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10
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13. Do you crave alcoholic beverages?
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10
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14. Does tobacco smoke really bother you?
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10
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Total Score, Section A __________________________________________
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** The use of nasal or bronchial sprays
cortisone and/or other steroids promotes overgrowth in the respiratory
tract.
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Section A Section
B Section C
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Incorporated - info@drrickettsnutri.com
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