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Yeast Questionnaire - Adult
In Section A circle the score for each YES answer. For Sections
B and C score as indicated. Record total scores at the end of the questionnaire. Add the totals to get your GRAND TOTAL SCORE.
Section A - History
1. Have you taken tetracyclines (Sumycin, Panmycin, Vibra- mycin, Minocin, etc.) or other antibiotics for acne for one
month or longer? ..........................................................................35
2. Have you ever taken other "broad spectrum" antibiotics for urinary, respiratory, or other infections for two months or longer, or in shorter courses four or more times in a
one year period? ...........................................................................35
3. Have you ever taken a "broad spectrum" antibiotic drug? .............6
4. Have you ever been bothered by persistent prostatitis,
vaginitis, or other reproductive organ problems?..........................25
5. Have you been pregnant: two or more times? ...............................5
1 time? ............................................................................................3
6. Have you taken birth control pills for more than two years? ........15
For six months to two years? .........................................................8
7. Have you taken prednisone, Decadron, or other cortisone-
type drugs for more than two weeks? ...........................................15
For two 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 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?
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
Enter the appropriate score for each symptom below.
If a symptom is occasional or mild Score 3 points
If a symptom is frequent or moderately severe Score 6 points
If a symptom is severe or disabling Score 9 points
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. Muscle aches .............................................................
8. Muscle weakness or paralysis....................................
9. Joint pain ....................................................................
10. Abdominal pain...........................................................
11. Constipation ...............................................................
12. Diarrhea......................................................................
13. Bloating ......................................................................
14. Troublesome vaginal discharge .................................
15. Persistent vaginal burning or itching ..........................
16. Prostatitis....................................................................
17. Impotence...................................................................
18. Loss of sexual desire..................................................
19. Endometriosis.............................................................
20. Cramps and/or other menstrual irregularities .............
21. Premenstrual tension .................................................
22. Spots in front of eyes..................................................
23. Erratic vision...............................................................
Section C - Other Symptoms
Enter the appropriate score for each symptom below.
If a symptom is occasional or mild Score 1 points
If a symptom is frequent or moderately severe Score 2 points
If a symptom is severe or disabling Score 3 points
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 tingling .........
9. Itching ......................................................................
10. Other rashes ............................................................
11. Heartburn.................................................................
12. Indigestion ...............................................................
13. Belching and intestinal gas ......................................
14. Mucus in stools ........................................................
15. Hemorrhoids ...........................................................
16. Dry mouth ................................................................
17. Rash or blisters in mouth .........................................
18. Bad breath ...............................................................
19. Joint swelling or arthritis ..........................................
20. Nasal congestion or discharge ................................
21. Postnasal drip .........................................................
22. Nasal itching ............................................................
23. Sore or dry throat.....................................................
24. Cough ......................................................................
25. Pain or tightness in chest ........................................
26. Wheezing or shortness of breath.............................
27. Urgency or urinary frequency .................................
28. Burning on urination ................................................
29. Failing vision ............................................................
30. Burning or tearing of eyes .......................................
31. Recurrent infections or fluid in ears .........................
32. Ear pain or deafness ...............................................
Scores: Section A Section B Section C
GRAND TOTAL SCORE
The GRAND TOTAL SCORE will help determine if your health problems are yeast connected. Scores in women will run higher because more questions apply only to women than to men.
Yeast connected health problems are almost CERTAINLY PRESENT in
women with scores over 180, and in men with scores over 140.
Yeast connected problems are PROBABLY PRESENT in women with scores over 120 and in men with scores over 90.
Yeast connected problems are POSSIBLY PRESENT in women with scores over 60 and in men with scores over 40.
Scores less than 60 in women and 40 in men: yeasts are less apt to cause
health problems.