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Wellness Programs
Candida Questionnaire
and Score Sheet
Name:
_________________________________________________ Age: _________
The questionnaire is
designed for adults and the scoring system isn't appropriate for children. It
lists factors in your medical history which promote the growth of Candida
Albicans (Section A), and symptoms commonly found in individuals with
yeast-connected illness (Sections B and C).
For each "Yes" answer in
Section A, circle the point score in that section. Record your total score in
the box at the end of the section. Then move on to Sections B and C and score as
directed.
Filling out and scoring
this questionaire should help you and your doctor evaluate the possible role of
Candida in contributing to your health problems. Yet it will not provide an
automatic "Yes" or "No" answer.
Section A: History
1. Have you taken
tetracyclines (Symycin, Panmycin, Vibramycin, Minocin, etc.) or other
antibiotics for acne for one month or longer? ........ 25
2. Have you, at any time
in your life, taken other "broad spectrum" antiobiotics* for respiratory,
urinary or other infections for 2 months or longer or in shorter courses 4 or
more times in a 1-year period? ........ 20
3. Have you taken a broad
spectrum antiobiotic* -- even in a single course? ........ 6
4. Have you, at anytime
in your life, been bothered by persistant prostatitis, vaginitis, or other
problems affecting your reproductive organs? ........ 25
5. Have been pregnant ..
2 or more times? ........ 5
1 time? ........ 3
* Including Keflex,
ampicillin, amoxicillin, Ceclor, Bactrim, and Septra. Such antibiotics kill off
"good germs" while they are killing off those which cause infection.
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 more than 2 weeks? ........ 15
For 2 weeks or less? ........ 6
8. Does exposure to
perfumes, insecticides, fabric shop odors, and other chemicals provoke
... Moderate to severe symptoms? ........ 20
Mild symptoms? ........ 5
9. Are your 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 fungus infections of the skin or
nails?
Have such infections been ...
Severe or persistent? ........ 20
Mild to moderate? ........ 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
Section B: Major Symptoms
For each of your symptoms,
enter the appropriate figure in the point score column:
Occassional or
Mild 3 points
Frequent
and/or Moderately Severe 6 points
Severe and/or
Disabling 9 points
Add total score and record
it in the box at the end of this section:
Point Score Point Score
1. Fatigue or
lethargy _______ 13.
Bloating _______
2. Feeling of being
"drained" _______ 14. Troublesome vaginal discharge
_______
3. Poor
memory _______ 15. Persistent vaginal burning or
itching ______
4. Feeling "spacey"
or "unreal" _______ 16. Prostatitis _______
5.
Depression _______ 17.
Impotence _______
6. Numbness, burning,
or tingling _______ 18. Loss of sexual desire
_______
7. Muscle
aches _______ 19.
Endometriosis _______
8. Muscle weakness or
paralysis _______ 20. Cramps and/or other menstrual
9. Pain and/or
swelling in joints _______ irregularities
_______
10. Abdominal
pain _______ 21. Premenstrual
tension _______
11.
Constipation _______ 22. Spots in front of the
eyes _______
12.
Diarrhea _______ 23. Erratic
vision _______
Section C: Other Symptoms
For each of your symptoms, enter the appropriate figure in the point score
column:
Occassional or
Mild 1 point
Frequent
and/or Moderately Severe 2 points
Severe and/or
Disabling 3 points
Add total score and record
it in the box at the end of this section:
Point Score
Point Score
1.
Drowsiness _______ 17. Rash or blister in
mouth _______
2. Irritability or
jitteriness _______ 18. Bad breath
_______
3. Incoordination
_______ 19. Joint swelling or arthritis _______
4. Inability to
concentrate _______ 20. Nasal congestion or discharge
_______
5. Frequent mood
swings _______ 21. Postnasal drip
_______
6.
Headache _______ 22. Nasal
itching _______
7. Dizziness/loss of
balance _______ 23. Sore or dry throat
_______
8. Pressure above
ears, feeling of 24. Cough
_______
head swelling and
tingling _______ 25. Pain or tightness in chest
_______
9.
Itching _______ 26. Wheezing or shortness of
breath _______
10. Other
rashes _______ 27. Urinary urgency or
frequency _______
11.
Heartburn _______ 28. Burning or tearing of
eyes _______
12.
Indigestion _______ 29. Failing
vision _______
13. Belching and
intestinal gas _______ 30. Burning on urination
_______
14. Mucus in
stools _______ 31. Recurrent infections or fluid in
ears_______
15.
Hemorrhoids _______ 32. Ear pain or
deafness _______
16. Dry
mouth _______
Total Score,
Section C _______
Total Score,
Section A _______
Total Score,
Section B _______
GRAND TOTAL
SCORE _______
The Grand Total Score will
help you and your doctor decide if your health problems are yeast-connected.
Scores in women will run higher as 7 items in the questionaire apply exclusively
to women, while only 2 apply exclusively to men. If your score is: Symptoms
are:
180
(women) Almost Certainly
140
(men) Yeast Connected
120
(women) Probably
90
(men) Yeast Connected
60
(women) Possibly
40
(men) Yeast Connected
Less Than:
60
(women) Probably Not
40
(men) Yeast Connected
Peace Eagle Herbs and Gifts.
Copyright © 2008 Peace Eagle Herbs & Gifts. All rights reserved.
Revised:
04/22/10
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