Candida Questionnaire and Score Sheet

Question	Point Score
1. Have you taken tetracycline's (or other antibiotics) for 2 months (or longer)?	25
2. Have you, at any time in your life, taken other "broad spectrum" antibiotics (Including Keflex®, ampicillin, amoxicillin, Ceclor®, Bactrim®, and Septra®*) 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, at any time in your life, been troubled by persistent vaginal problems or had 3 or more episodes of vaginitis in a year?	25
4a. Have you been pregnant 2 or more times? 4b. Have you been pregnant 1 time?	5 3
5a. Have you taken birth control pills for more than 2 years? 5b. For 6 months to 2 years?	15 8
6a. Have you taken prednisone, Decadron® or other cortisone-type drugs for more than 2 weeks? 6b. For 2 weeks or less?	15 6
7a. Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke... Moderate to severe symptoms? 7b. Mild symptoms?	20 5
8. Are your symptoms worse on damp, muggy days or in moldy places?	20
9a. Have you had persistent athlete's foot, "jock itch", or other chronic fungous infections of the skin or nails? Have such infections been ... Severe or persistent? 9b. Mild to moderate?	20 10
10. Do you crave sugar?	10
11. Do you crave breads?	10
12. Do you crave alcoholic beverages?	10
13. Does tobacco smoke really bother you?	10

TOTAL SCORE, Section A

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*Such antibiotics kill off "good germs" while they're killing off those which cause infection.



Section B: History

For each symptom which is present, enter the appropriate figure in the Point Score column:

If a symptom is mild: score 3 points.
If a symptom is moderate: score 6 points.
If a symptom is severe or disabling: score 9 points.

Add total score for this section and record it on the line at the end of this section.

Symptom	Point Score
1. Fatigue or lethargy.
2. Feeling of being "drained"
4. Feeling "spacey " or "unreal"
5. Depression
6. Numbness, burning or tingling
7. Muscle aches
8. Muscle weakness or paralysis
9. Pain and/or swelling in joints
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 feeling
19. Endometriosis
20. Dysmenorrhea
21. Premenstrual tension
22. Spots in front of eyes
23. Erratic Vision

TOTAL SCORE, Section B

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Section C: Other Symptoms

For each symptom which is present, enter the appropriate figure in the Point Score column:

If a symptom is mild: score 1 points.
If a symptom is moderate: score 2 points.
If a symptom is severe or disabling: score 3 points.

Add total score for this section and record it on the line at the end of this section.

*While the symptoms in this section occur commonly in patients with yeast-connected illness, they also occur commonly in patients who do not have candida.

Symptom	Point Score
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 and 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 eyes
31. Recurrent ear infections
32. Fluid in ears
33. Ear pain or deafness
34. Tubes in ears
35. Other symptoms

TOTAL SCORE, Section C

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GRAND TOTAL SCORE (Add up Total Score for Sections A, B, and C)

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