Welcome to your Welcome to your Candida Screening Questionnaire Answering these questions and adding up the scores will help you and your clinician decide if yeast may be contributing to your health problems. For each section read the directions and score as indicated. Total your score and record it at the end of the section. Add the totals for each section to get your Total Score 1. Have you taken tetracyclines (Sumycin, Panmycino, Vibramycin, Minocin, etc.) or other antibiotics for acne for one month (or longer)? Yes No None 2. Have you, at any time in your life, taken other “broad spectrum” antibiotics* for respiratory, urinary, or other infections (for two months or longer, or in shorter courses four or more times in a one-year period)? Yes No None 3. Have you taken a broad spectrum antibiotic drug*, even a single course? Yes No None 4. Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your reproductive organs? Yes No None 5. Have you been pregnant? One time? Two or more times? None None 6. Have you taken birth control pills? For six months to two years? For more than two years? Less than 6 months / Never None 7. Have you taken prednisone, decadron or other cortisone-type drugs? For two weeks or less? For more than two weeks? Never None 8. Does exposure to perfumes, insecticides, fabric shop odors, and other chemicals provoke symptoms? Mild symptoms? Moderate to severe symptoms? None None 9. Are your symptoms worse on damp, muggy days or in moldy places? Yes No None 10. Have you had athlete’s foot, ringworm, “jock itch,” or other chronic fungus infections of the skin or nails? Mild to moderate? Severe or persistent? Never None 11. Do you crave sugar? Yes No None 12. Do you crave breads? Yes No None 13. Do you crave alcoholic beverages? Yes No None 14. Does tobacco smoke really bother you? Yes No None SECTION B: MAJOR SYMPTOMS None 1. Fatigue or lethargy Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 2. Feeling of being “drained” Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 3. Poor memory Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 4. Depression Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 5. Feeling “spacey” or “unreal” Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 6. Inability to make decisions Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 7. Numbness, burning, or tingling Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 8. Muscle aches or weakness Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 9. Pain and/or swelling in joints Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 10. Abdominal pain Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 11. Constipation Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 12. Diarrhea Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 14. Troublesome vaginal burning, itching, or discharge Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 16. Prostatitis Yes Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 18. Loss of sexual desire or feeling Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 19. Endometriosis or infertility Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 20. Cramps and/or other menstrual irregularities Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 21. Premenstrual tension Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 22. Attacks of anxiety or crying Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 23. Cold hands or feet and/or chilliness Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 24. Shaking or irritable when hungry Occasional and/or Mild Frequent and/ or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None SECTION C: OTHER SYMPTOMS None 1. Drowsiness Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 2. Irritability or jitteriness Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 3. Uncoordination Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 4. Inability to concentrate Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 5. Frequent mood swings Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 6. Headache Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 7. Dizziness/loss of balance Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 8. Pressure above ears, feeling of head swelling Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 9. Tendency to bruise easily Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 10. Chronic rashes or itching Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 11. Numbness, tingling Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 12. Indigestion or heartburn Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 13. Food sensitivity or intolerance Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 14. Mucus in stools Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 16. Dry mouth or throat Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 17. Rash or blisters in mouth Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 18. Bad breath Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 19. Foot, body, or hair odor not relieved by washing Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 20. Nasal congestion or postnasal drip Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 21. Nasal itching Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 22. Sore throat Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 23. Laryngitis, loss of voice Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 24. Cough or recurrent bronchitis Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 25. Pain or tightness in chest Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 26. Wheezing or shortness of breath Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 27. Urgency or urinary frequency Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 28. Burning on urination Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 29. Spots in front of eyes or erratic vision Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 30. Burning or tearing of eyes Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 31. Recurrent infections or fluid in ears Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None 32. Ear pain or deafness Occasional and/or Mild Frequent and/or Moderately Severe Very Frequent and/or Very Severe or Disabling Does not apply None The Total Score will help you and your clinician decide if your health problems are yeast connected. Scores in women will run higher as seven items in the questionnaire apply exclusively to women, while only two apply exclusively to men Men 40 or below - Yeast is less apt to cause health problems 41-90 - Yeast-connected health problems are possibly present 91-140 - Yeast-connected health problems are probably present 141 or higher -Yeast-connected health problems are almost certainly present Women 60 or below - Yeast is less apt to cause health problems 61-121 - Yeast-connected health problems are possibly present 121-180 - Yeast-connected health problems are probably present 181 or higher -Yeast-connected health problems are almost certainly present Time's up
