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Microsoft word - candida questionnaire and score sheet.doc

Fairfield Spine Center, LLC • 1600 Sheridan Dr. • Lancaster, OH • 43130 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 (Sections 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. 1. Have you taken tetracyclines (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics for 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 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 2 years? 7. Have you taken Prednisone, Decadron or other cortisone type drugs by mouth or inhalation for more 8. Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke. moderate to 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 severe or persistent? Mild or moderate? 14. Does tobacco smoke really bother you? 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 severe and/or disabling.score 9 points. Add total score for this section and record it in the box 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 For each symptom which is present, enter the appropriate figure in the Point Score column: If a symptom is occasional or mild.score 1 point. If a symptom is frequent and/or moderately severe.score 2 points. If a symptom is severe and/or persistent.score 3 points. Add total score for this section and record it in the box at the end of this section. 8. Pressure above ears. feeling of head swelling 19. Foot, hair or body odor not relieved by washing (This section is continued on the next page.) * 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. Occasional or mild symptoms.score 1 point. Frequent and/or moderate symptoms.score 2 points. Severe and/or persistent symptoms.score 3 points. 27. Urinary frequency, urgency or incontinence 29. Spots in front of eyes or erratic vision 31. Recurrent infections or fluid in ears 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 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 of less than 60 in women and 40 in men, yeasts are less apt to cause health problems. * Filling out and scoring this questionnaire should help you and your physician evaluate the role 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. ** The use of nasal or bronchial sprays containing cortisone and/or other steroids, promote yeast overgrowth in the respiratory tract.

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