CANDIDA QUESTIONNAIRE AND SCORE SHEET Susan Swanson, State Certified Herbalist, Iridologist (970) 689-9576; firstname.lastname@example.org; www.solereflex.com
This questionnaire lists factors in your medical history which promote the growth of the common yeast Candida albicans (Section A), and symptoms commonly found in individuals with yeast-connected illness (Section B and C).
For each "Yes" answer in Section A, circle the Point Score in that section. Total your score and record it in the box 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 tetracyclines (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics for
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 in shorter courses 4 or more times in a 1-year period)?
3 Have you taken a broad spectrum antibiotic drug - even in a single course?
4 Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems
5 Have you been pregnant 2 or more times?
6 Have you taken birth control pills for…
more than 6 months but less than 2 years?
7 Have you taken prednisone, Decadron or other cortisone-type drugs by mouth or inhalation …
8 Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke …
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 fungous infections of the skin or
nails? Have such infections been … moderate to severe symptoms?
Total Score, Section A SECTION B: MAJOR SYMPTOMS
For each symptom which is present, enter the appropriate figure 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 occasional or severe and/or disabling …………….score 9 points. Add total score for this section and record it in the box at the box at the end of this section.
1 Fatigue or lethargy2 Feeling of being "drained"3 Poor memory4 Feeling "spacey" or "unreal"5 Inability to make decisions6 Numbness, burning or tingling7 Insomnia8 Muscle aches9 Muscle weakness or paralysis
10 Pain and/or swelling in joints11 Abdominal pain12 Constipation13 Diarrhea14 Bloating, belching or intestinal gas15 Troublesome vaginal burning, itching or discharge16 Prostatitis17 Impotence18 Loss of sexual desire or feeling19 Endometriosis or infertility20 Cramps and/or other menstrual irregularities21 Premenstrual tension22 Attacks of anxiety or crying23 Cold hands or feet and/or chilliness24 Shaking or irritable when hungry
Total Score, Section B
SECTION B: MAJOR SYMPTOMSFor each symptom which is present, enter the appropriate figure in the Point Score column: If a symptom is occasional or mild ………………………………….score 1 points. If a symptom is frequent and/or moderately severe ……….……….score 2 points. If a symptom is occasional or severe and/or persistent …….…….score 3 points. Add total score for this section and record it in the box at the box at the end of this section.
1 Drowsiness2 Irritability or jitteriness3 Incoordination4 Inability to concentrate5 Frequent mood swings6 Headache7 Dizziness/loss of balance8 Pressure above ears … feeling of head swelling9 Tendency to bruise easily
10 Chronic rashes or itching11 Psoriasis or recurrent hives12 Indigestion or heartburn13 Food sensitivity or intolerance14 Mucus in stools15 Rectal itching16 Dry mouth or throat17 Rash or blisters in mouth18 Bad breath19 Foot, hair or body odor not relieved by washing20 Nasal congestion or post nasal drip21 Nasal itching22 Sore throat23 Laryngitis, loss of voice24 Cough or recurrent bronchitis25 Pain or tightness in chest26 Wheezing or shortness of breath27 Urinary frequency, urgency, or incontinence28 Burning or urination29 Spots in front of eyes or erratic vision30 Burning or tearing of eyes31 Recurrent infections or fluid in ears32 Ear pain or deafness
Total Score, Section C Total Score, Section A Total Score, Section B Total Score, Section C GRAND TOTAL SCORE (Add up Total Score 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 in women will run higher as 7 items in the 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 almost probably present in women with scores over 120., and in men with scores over 90.
Yeast-connected health problems are almost possibly present in women with scores over 60., and in men with scores over 40.
With scores of less than 60 in women and 40 in men yeasts are less apt to cause health problems.
PICA Drug List - Alphabetial Listing Key: MAND. MAIL = the indicated medication must be ordered through CFI Mail Order. STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or generics) first FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after on