Candida Questionnaire

Female Specific History
1-3 circle the score. 4-7 use scoring points below. 
Total the scores for this section and record at the bottom of the section.
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 and/or disabling, score 9 points.


1.  Have you at any time in your life, been bothered by persistent vaginitis or other problems affecting your reproductive organs?   ______  25

2.  Have you been pregnant…
       a. 2 or more times?  ____  5
       b. 1 time?    ____  3

3.  Have you taken birth control pills for…
       a. More than 2 years?  ___
       b. 6 months to 2 years?   ___

4.  Troublesome vaginal burning, itching, or discharge     ____

5.  Endometriosis or infertility   ____

6.  Severe cramps and/or other menstrual irregularities    ____

7.  Premenstrual tension    ____

 

 

Candida Questionnaire
* Indicates required field
Date *
Name *
First
Last
Section A: History
​Circle the score to the right of each question when a response is “yes”, then add up all the circled numbers and write the total at the bottom of the section
1. Have you taken tetracycline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics for acne for 1 month or longer? _____ (25)

2. Have you at any time in your life, taken other “broad spectrum” antibiotics for respiratory, urinary or other infections for 2 months or longer, or for shorter periods, 4 or more times in a 1 year span? _____ (20)

​3. Have you taken a broad spectrum antibiotic drug – even for one period? _____ (6)

​4. Have you taken prednisone, Decradon, or other cortisone-type drugs by mouth or inhalation…
For more than 2 weeks? _____ (15)
For 2 weeks or less? _____ (6)

​5. If you have ever had thrush, athlete’s foot, ringworm, jock itch or other chronic fungus infections of the skin or nails, have such infections been…
Severe or persitent? _____ (20)
Mild or moderate? _____ (10)

6. Do you crave sugar/sweets? _____ (10)

7. Do you crave breads? _____ (10)

8. Do you crave alcoholic beverages? _____ (10)
Section A Total Score:
Section B: Secondary Indicators
For each symptom that is present, enter the appropriate number in the Point Score column:
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 and/or disabling, score 9 points.
Total the scores for this section and record them at the end of the section.
1. Fatigue or lethargy ______
2. Feeling of being “drained” ______
3. Drowsiness ______
4. Feeling “foggy” or “spacey” _____
5. Inability to make decisions _____
6. Inability to concentrate _____
7. Poor memory _____
8. Frequent mood swings _____
9. Attacks of anxiety or crying _____
10. Headaches _____
11. Abdominal pain _____
12. Constipation _____
13. Diarrhea ______
14. Bloating, belching, or intestinal gas ______
15. Indigestion or heartburn _____
16. Chronic rashes or itching ______
17. Psoriasis or recurrent hives ______
18. Rectal itching ______
Section B: Total Score
Section C: Minor Indicators
For each symptom that is present, enter the appropriate number in the Point Score column:
If a symptom is occasional or mild, score 1 point.
If a symptom is frequent or moderately severe, score 3 points.
If a symptom is severe and/or disabling, score 5 points.
Total the scores for this section and record them at the end of the section.
1. Irritability or jitteriness ______
2. Dizziness/loss of balance ______
3. Pressure above eyes or in ears; feeling of head swelling ______
4. Tendency to bruise easily _____
5. Food sensitivity or intolerance _____
6. Dry mouth or throat _____
7. Bad breath _____
8. Foot, hair, or body odor not relieved by washing _____
9. Nasal congestion or post-nasal drip _____
10. Nasal itching _____
11. Sore throat _____
12. Laryngitis, loss of voice _____
13. Cough or recurrent bronchitis ______
14. Burning or tearing of eyes ______
15. Recurrent infections or fluid in ears _____
16. Ear pain or deafness ______
17. Numbness, burning, or tingling ______
18. Muscle aches ______
19. Muscle weakness or paralysis ______
20. Pain and/or swelling in joints ______
21. Impotence ______
22. Urinary frequency, urgency, or incontinence ______
23. Burning on urination ______
24. Loss of sexual desire or feeling ______
Section C Total Score
Female Specific History
1-3 circle the score. 4-7 use scoring points below. Total the scores for this section and record at the bottom of the section.
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 and/or disabling, score 9 points.

1. Have you at any time in your life, been bothered by persistent vaginitis or other problems affecting your reproductive organs? ______ 25

2. Have you been pregnant…
a. 2 or more times? ____ 5
b. 1 time? ____ 3

3. Have you taken birth control pills for…
a. More than 2 years? ___
b. 6 months to 2 years? ___

4. Troublesome vaginal burning, itching, or discharge ____

5. Endometriosis or infertility ____

6. Severe cramps and/or other menstrual irregularities ____

7. Premenstrual tension ____
Combined Score
Section A _____ /116
Section B _____ /162
Section C _____ /120
Female specific _____ /81

Total Score: ___________
Women Men
0-90 0-78 Candida unlikely an issue
88-229 76-196 Candida possibly present
223-479 190-398 Candida likely present

Section A: History
Circle the score to the right of each question when a response is “yes”, then add up all the circled numbers and write the total at the bottom of the section
1. Have you taken tetracycline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics for acne for 1 month or longer? _____ (25)

2. Have you at any time in your life, taken other “broad spectrum” antibiotics for respiratory, urinary or other infections for 2 months or longer, or for shorter periods, 4 or more times in a 1 year span? _____ (20)

3. Have you taken a broad spectrum antibiotic drug – even for one period? _____ (6)

4. Have you taken prednisone, Decradon, or other cortisone-type drugs by mouth or inhalation…
For more than 2 weeks? _____ (15)
For 2 weeks or less? _____ (6)

5. If you have ever had thrush, athlete’s foot, ringworm, jock itch or other chronic fungus infections of the skin or nails, have such infections been…
Severe or persitent? _____ (20)
Mild or moderate? _____ (10)

6. Do you crave sugar/sweets? _____ (10)

7. Do you crave breads? _____ (10)

8. Do you crave alcoholic beverages? _____ (10)

 

Section B: Secondary Indicators

For each symptom that is present, enter the appropriate number in the Point Score column:

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 and/or disabling, score 9 points.

Total the scores for this section and record them at the end of the section.

1.  Fatigue or lethargy                                    ______

2.  Feeling of being “drained”                      ______

3.  Drowsiness                                         ______

4.  Feeling “foggy” or “spacey”                     _____

5.  Inability to make decisions                     _____

6. Inability to concentrate                             _____

7.  Poor memory                                              _____

8.  Frequent mood swings                            _____

9.  Attacks of anxiety or crying                     _____

10.  Headaches                                                  _____

11.  Abdominal pain                                          _____

12.  Constipation                                                _____

13.  Diarrhea                                                       ______

14.  Bloating, belching, or intestinal gas     ______

15.  Indigestion or heartburn                    _____

16.  Chronic rashes or itching                        ______

17.  Psoriasis or recurrent hives                     ______

18.  Rectal itching                                             ______

 

 

Candida Questionnaire

* Indicates required field

Date *

Name *

First

Last

Section A: History

Circle the score to the right of each question when a response is “yes”, then add up all the circled numbers and write the total at the bottom of the section

1.  Have you taken tetracycline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics for acne for 1 month or longer?   _____ (25)

 

2.  Have you at any time in your life, taken other “broad spectrum” antibiotics for respiratory, urinary or other infections for 2 months or longer, or for shorter periods, 4 or more times in a 1 year span?  _____     (20)

 

3.  Have you taken a broad spectrum antibiotic drug –  even for one period?    _____  (6)

 

4.  Have you taken prednisone, Decradon, or other cortisone-type drugs by mouth or inhalation…

        For more than 2 weeks?  _____ (15)

        For 2 weeks or less?   _____ (6)

 

5.  If you have ever had thrush, athlete’s foot, ringworm, jock itch or other chronic fungus infections of the skin or nails, have such infections been…

         Severe or persitent? _____ (20)

         Mild or moderate?   _____ (10)

 

6.  Do you crave sugar/sweets?  _____ (10)

 

7.  Do you crave breads?   _____ (10)

 

8.  Do you crave alcoholic beverages?   _____ (10)

Section A Total Score:

Section B: Secondary Indicators

For each symptom that is present, enter the appropriate number in the Point Score column:

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 and/or disabling, score 9 points.

Total the scores for this section and record them at the end of the section.

1.  Fatigue or lethargy                                    ______

2.  Feeling of being “drained”                      ______

3.  Drowsiness                                         ______

4.  Feeling “foggy” or “spacey”                     _____

5.  Inability to make decisions                     _____

6. Inability to concentrate                             _____

7.  Poor memory                                              _____

8.  Frequent mood swings                            _____

9.  Attacks of anxiety or crying                     _____

10.  Headaches                                                  _____

11.  Abdominal pain                                          _____

12.  Constipation                                                _____

13.  Diarrhea                                                       ______

14.  Bloating, belching, or intestinal gas     ______

15.  Indigestion or heartburn                    _____

16.  Chronic rashes or itching                        ______

17.  Psoriasis or recurrent hives                     ______

18.  Rectal itching                                             ______

 

 

Section C: Minor Indicators

For each symptom that is present, enter the appropriate number in the Point Score column:

If a symptom is occasional or mild, score 1 point.

If a symptom is frequent or moderately severe, score 3 points.

If a symptom is severe and/or disabling, score 5 points.

Total the scores for this section and record them at the end of the section.

1.  Irritability or jitteriness                                                                      ______

2.  Dizziness/loss of balance                                                                 ______

3.  Pressure above eyes or in ears; feeling of head swelling       ______

4.  Tendency to bruise easily                                                                _____

5.  Food sensitivity or intolerance                                                       _____

6. Dry mouth or throat                                                                          _____

7.  Bad breath                                                                                           _____

8.  Foot, hair, or body odor not relieved by washing                      _____

9.  Nasal congestion or post-nasal drip                                             _____

10.  Nasal itching                                                                                      _____

11.  Sore throat                                                                                           _____

12.  Laryngitis, loss of voice                                                                    _____

13.  Cough or recurrent bronchitis                                                       ______

14.  Burning or tearing of eyes                                                              ______

15.  Recurrent infections or fluid in ears                                    _____

16.  Ear pain or deafness                                                                         ______

17.  Numbness, burning, or tingling                                                    ______

18.  Muscle aches                                                                                      ______

19.  Muscle weakness or paralysis                                                        ______

20.  Pain and/or swelling in joints                                                        ______

21.  Impotence                                                                                           ______

22.  Urinary frequency, urgency, or incontinence                           ______

23.  Burning on urination                                                                       ______

24.  Loss of sexual desire or feeling                                                      ______

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