A Questionnaire For Assessing Yeast Related Health Problems

Section A: History

Instructions: For each yes answer in section A, Circle the Point Score in that section. Total your score and record it in the box at the end of the section. Then move on to Sections B and C, scoring as directed.

1.

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

50

2.

Have you ever taken other broad spectrum* antibiotics for urinary, respiratory or other infections for 2 months or longer, or in shorter courses 4 or more times in a 1 year period?

 * Including Keflex, ampicillin, amoxicillin, Ceclor, Bactrim, and Septra. Such antibiotics kill off "good germs" while they are killing off those which cause infection.

50

3.

Have you ever taken a "broad spectrum" antibiotic drug – even for one course?

6

4.

Have you ever been bothered by persistent prostatitis, vaginitis, or other problems that affect your reproductive organs?

 25

5.

Have you ever been pregnant:

1 time?

3

2 or more times?

5

6.

Have you taken birth control pills:

for more than 2 years?

15

for 6 months to 2 years?

8

7.

Have you taken prednisone, Decadron or other cortisone type drugs:

for 2 weeks or less?

6

for more than 2 weeks?

15

8.

Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke:

mild symptoms?

5

moderate to severe symptoms?

20

9.

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

20

10.

Have you had athlete’s foot, ring worm, "jock itch" or other chronic fungous infections of the skin or nails?

mild to moderate symptoms?

10

moderate to severe symptoms?

20

11.

Do you crave sugar?

10

12.

Do you crave breads or other foods high in carbohydrates? 

10

13.

Do you crave alcoholic beverages?

10

14.

Does tobacco smoke really bother you?

10

Total Score – Section A

Section B: Major Symptoms

Instructions: For each symptom that is present, enter the appropriate number in the Point Score Column.

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.

Total the score for this section and record it in the box at the end of this section.

1.

Fatigue or lethargy

2.

Feeling of being "drained"

3.

Poor memory

4.

Feeling "spacey" or "unreal"

5.

Depression

6.

Numbness, burning or tingling

7.

Insomnia

8.

Muscle aches

9.

Muscle weakness or paralysis

10.

 Joint pain or swelling

11.

Abdominal pain

12.

Constipation

13.

Diarrhea

14.

Bloating, belching or intestinal gas

15.

Troublesome vaginal burning, itching or discharge

16.

Prostatitis

17.

Impotence

18.

Loss of sexual desire or feeling

19.

Endometriosis or infertility

20.

Cramps and/or other menstrual irregularities

21.

Premenstrual tension

22.

Attacks of anxiety or crying

23.

Cold hands or feet and/or chilliness

24.

Shaking or irritable when hungry

Total Score – Section B

Section C: Other Symptoms

Instructions: For each symptom that is present, enter the appropriate number in the Point Score Column.

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.

Total the score for this section and record it in the box at the end of this section.

1.

Drowsiness

2.

Irritability or jitteriness

3.

Incoordination

4.

Inability to concentrate

5.

Frequent mood swings

6.

Headache

7.

Dizziness/loss of balance

8.

Pressure above ears, feeling of head swelling/tingling

9.

Tendency to bruise easily

10.

Chronic rashes or itching

11.

Psoriasis or recurrent hives

12.

Indigestion or heartburn

13.

Food sensitivity or intolerance

14.

Mucus in stools

15.

Hemorrhoids or rectal itching

16.

Dry Mouth or throat

17.

Rash or blisters in mouth

18.

Bad breath

19.

Foot, hair or body odor not relieved by washing

20.

Nasal congestion, discharge or post nasal drip

21.

Nasal itching

22.

Sore or dry throat

23.

Laryngitis, loss of voice

24.

Cough or recurrent bronchitis

25.

Pain or tightness in chest

26.

Wheezing or shortness of breath

27.

Urgency frequency, urgency or incontinence

28.

Burning on urination

29.

Spots in front of eyes or erratic vision

30.

Burning or tearing of eyes

31.

Recurrent infections or fluid in ears

32.

Ear pain or deafness

Total Score – Section C

Test Scoring & Results

Total Score – Section A

Total Score – Section B

Total Score – Section C

Grand Total Score (add sections A, B & C)

The Grand Total Score will help you and your health care provider decide if your health problems are yeast-connected.

Scores for woman will typically run higher. Yeast-connected health problems are almost certainly present in woman with scores over 180, and in men with scores over 140.

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

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

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