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Yeast Questionnaire - Long Version
This questionnaire lists factors in your medical history that promote the growth of the common yeast, Candida Albicans (Section A), and symptoms commonly found in individuals with yeast-connected illness (Sections B and C). *Filling out and scoring this questionnaire should help you and your physician evaluate how Candida Albicans may be contributing to your health problems. Yet it will not provide an automatic yes or no answer. A comprehensive history and physical examination are important. In addition, laboratory studies, x-rays, and other types of tests may also be appropriate. For each yes answer in Section A, circle the Point Score. 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 Point Score
1. Have you taken tetracyclines (Sumycin®, Panmycin®, Vibramycin®,Minocin®, etc.) or other antibiotics
for acne for 1 month (or longer)?
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? Point score: 50 3. Have you taken a broad spectrum antibiotic drug – even for one period? 4. Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your reproductive organs? 5. Have you been pregnant 2 or more times? 6. Have you taken birth control pills for more than 2 years? Taken birth control pills 6 months to 2 years? 7. Have you taken Prednisone, Decadron®, or other cortisone-type drugs by mouth or inhalation** for more than 2 weeks? 8. Does exposure to perfumes, insecticides, fabric shop odors, or other chemicals provoke moderate to severe symptoms? 9. Are your symptoms worse on damp, muggy days or in moldy places? 10.Have you had athlete’s foot, ringworm, "jock itch" or other chronic fungus infections of the skin or nails that have been severe or persistent? 14. Does tobacco smoke really bother you?
Total Score, Section A _______
**The use of nasal or bronchial sprays containing cortisone and/or other steroids promotes overgrowth in
the respiratory tract.

Section B: Major Symptoms

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 and/or moderately severe, score 6 points.
If a symptom is severe and/or disabling, score 9 points.
Circle the symptom score and total the score for this section, and record it at the end of this section. 4. Feeling "spacey" or "unreal" 14. Bloating, belching or intestinal gas 15.Troublesome vaginal burning, itching or discharge 20. Cramps and/or other menstrual irregularities 23. Cold hands or feet and/or chilliness
Total Score, Section B_______
Section C: Other Symptoms*

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 and/or moderately severe, score 6 points.
If a symptom is severe and/or persistent, score 9 points.
Circle the symptom score and total the score for this section, and record it at the end of this section. 8.Pressure above ears, feeling of head swelling 19. Foot, hair or body odor not relieved by washing 27. Urinary frequency, urgency or incontinence 29. Spots in front of eyes or erratic vision 31. Recurrent infections or fluid in ears
Total Score, Section C _______
*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. Total Score, Section C _______
Total Score, Section B _______
Total Score, Section A _______
Grand Total Score
(add totals from Sections A, B and C) _______
The Grand Total Score will help you and your physician decide if your health problems are yeast-
connected.
Scores for women will run higher, as 7 items in this questionnaire apply exclusively to women, while only 2 apply exclusively 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 health problems are probably present in women with scores over 120, and in men with scores over 90. Yeast-connected health problems are possibly present in women with scores over 60, and in men with scores over 40. With scores less than 60 for women and 40 for men, yeast are less apt to cause health problems.

Source: http://www.stopyeast.com/YeastQuestionnaire.pdf