For each 'Yes' answer in Section A, circle the Point Score in that section. Total your score and record it at the end of the section. Then move on to Sections B and C and score as directed.
Section A: History
1. | | Have you taken tetracycline (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 two months or longer, or in shorter courses four or more times in a one-year period? | 20 |
| 3. | | Have you, at any time in your life, been troubled by persistent vaginal problems or had three or more episodes of vaginitis in a year? | 25 |
| 4. | | Have you been pregnant more than twice? | 5 |
| | Have you been pregnant once? | 3 |
| 5. | | Have you taken birth control pills for more than two year? | 15 |
| | For six months to two years? | 18 |
| 6. | | Have you taken prednisone, Decadron® or other cortisone-type drugs for more than two weeks? | 15 |
| | For less than two weeks? | 6 |
| 7. | | Does exposure to perfumes, insecticides, fabric shop odours and other chemicals provoke... | |
| | Moderate to severe symptoms? | 20 |
| | Mild symptoms? | 5 |
| 8. | | Are your symptoms worse on damp, muggy days or in mouldy places? | 20 |
| 9. | | Have you had persistent athlete's foot, 'jock itch' or other chronic fungal infections of the skin or nails? Have such infections been ... | |
| | Severe or persistent? | 20 |
| | Mild to moderate? | 10 |
| 10. | | Do you crave sugar? | 10 |
| 11. | | Do you crave breads? | 10 |
| 12. | | Do you crave alcohol | 10 |
| 13. | | Does tobacco smoke really bother you? | 10 |
Section B: Major Symptoms
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
- Fatigue or lethargy.
- Feeling of being 'drained'
- Poor memory
- Feeling 'spacey' or 'unreal'
- Depression
- Numbness, burning or tingling
- Muscle aches
- Muscle weakness or paralysis
- Pain and/or swelling in joints
- Abdominal pain
- Constipation
- Diarrhoea
- Bloating
- Troublesome vaginal discharge
- Persistent vaginal burning or itching
- Prostatitis (inflamed, enlarged prostate)
- Impotence
- Loss of sexual feeling
- Endometriosis
- Dysmenorrhea (painful periods)
- Premenstrual tension
- Spots in front of eyes
- Erratic Vision
Total Score Section B =
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 point
If a symptom is moderate, score 2 points
If a symptom is severe or disabling, score 3 points
While the symptoms in this section occur commonly in patients with yeast-connected illness, they also occur commonly in patients who do not have an overgrowth of Candida.
- Drowsiness
- Irritability or jitteriness
- Incoordination
- Inability to concentrate
- Frequent mood swings
- Headache
- Dizziness/loss of balance
- Pressure above ears...feeling of head swelling and tingling
- Itching
- Other rashes
- Heartburn
- Indigestion
- Belching and intestinal gas
- Mucus in stools
- Hemorrhoids
- Dry mouth
- Rash or blisters in mouth
- Bad breath
- Joint swelling or arthritis
- Nasal congestion or discharge
- Postnasal drip
- Nasal itching
- Sore or dry throat
- Cough
- Pain or tightness in chest
- Wheezing or shortness of breath
- Urgency or urinary frequency
- Burning on urination
- Failing vision
- Burning or tearing eyes
- Recurrent ear infections
- Fluid in ears
- Ear pain or deafness
- Tubes in ears
- Other symptoms:
Total Score Section C =
Section A ............
Section B ............
Section C ............
Total ............