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Candida Long Questionnaire
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Candida Long Questionnaire

Candida Short Questionnaire

Blood Sugar Questionnaire

Syndrome X Questionnaire

  

This is the long questionnaire designed for adults and isn’t appropriate for children. It is based on a questionnaire created by William G. Crook M.D. and his book The Yeast Connection. Modifications have been made to suit our clientele. It is appropriate to fill this out questionnaire every two years or so, and check if the risk factors or symptoms related to Candida have increased enough to consider it an issue. There is a shorter questionnaire also. It helps keeps track of your symptoms on an ongoing basis. It can tell you when you are finished with the Candida problem.

This questionnaire lists factors in your medical history which can promote the growth of Candida albicans (Section I) and symptoms commonly found in people that have a Candida problem (Sections II and III). If the question applies in Section I, circle the number and add the score. In Sections II and III you are asked to rate symptoms. By adding all these numbers together we can derive the probability of having a Candida (yeast) problem. This questionnaire is not definitive. On its own, it cannot determine with absolute certainty whether or not you have a problem.

What is your gender? 
Male
Female


Section I: HISTORY

Place a checkmark if the answer is a 'yes' to the question:
1.

 Have you taken antibiotics (such as tetracyclines for acne) for two months or longer? (25)



2.


 Have you, at any time in your life, taken a broad spectrum antibiotic for respiration, urinary or other infection (for more than two months or longer, or 4 or more short courses within a year)? (20)


3.

 Have you ever had a persistent vaginal infection or more than 3 episodes in one year? (25)

4. Have you been pregnant two or more times? (5)
... one time ? (3)
5. Have you ever taken birth control pills for more than two years? (15)
... six months to 2 years? (8)
6.

 Have you ever taken cortisol-type drugs (e.g. prednisone, decadron etc.) for more than two weeks? (15)
... two or fewer weeks? (6)
7.
 Do you get a negative response to perfumes, insecticides or chemicals? 
... with moderate to severe symptoms? (20)
... mild symptoms? (5)
8. Do damp days or moldy places make your symptoms worse? (25)
9.

 Do you have persistent athlete's foot, “jock itch”, or other fungus on skin or nails?
... severe or persistent (25)
... mild to moderate (10)
10. Do you crave sugar? (15)
11. Do you crave bread? (20)
12. Do you crave alcoholic beverages?  (10)
13. Does tobacco smoke really bother you? (15)



Total points Section I:


Section II: Major Symptoms

For each symptom which is present, enter the appropriate score:


if mild 3 points
if moderate 6 points
if severe 9 points



Add the total below

None Mild Moderate Severe
1. Fatigue or lethargy
2. Feeling of being “drained”
3. Poor memory
4. Feeling “spacey” or “unreal”
5. Depression
6. Numbness, burning or tingling
7. Muscle aches and pains
8. Muscle weakness or partial paralysis
9. Pain and/or swollen joints
10. Abdominal bloating or pain
11. Constipation
12. Diarrhea
13. Bloating in general
14. Troublesome vaginal discharge
15. Persistent vaginal burning or itching
16. Enlarged prostate
17. Impotency
18. Loss of sex drive
19. Pelvic inflammatory disease or endometriosis
20. Problems with menstrual cycle
21. Premenstrual tension
22. Spots in front of eyes
23. Erratic vision




Total points Section II:



Section III: Other Symptoms

For each symptom present, enter the appropriate point value in the column.

if mild 1 point
if moderate 2 points
if severe 3 points


None Mild Moderate Severe
1. Drowsiness
2. Irritability or jitteriness
3. Poor co-ordination
4. Concentration problems
5. Mood swings
6. Headaches
7. Dizziness/vertigo/loss of balance
8. Feeling of swollen head or tingling pressure above ears
9. Itching
10. Rashes
11. Heartburn
12. Indigestion
13. Intestinal gas or belching
14. Mucus in stools
15. Hemorrhoids
16. Dry mouth
17. Blisters, cancer or rash in mouth
18. Bad breath
19. Swollen joints
20. Nasal congestion or discharge
21. Postnasal drip
22. Dry or sore throat
23. Nasal itching
24. Coughing
25. Pain or tightness in chest
26. Wheezing or shortness of breath
27. Urinary frequency or urgency
28. Burning on urination
29. Failing vision
30. Burning or tearing of eyes
31. Recurrent ear infections
32. Fluid in ears
33. Ear pain or deafness
34. Tubes in ears
35. Low thyroid
36. Other symptoms




Total points Section III:





Grand Total Score 
( Add Sections I, II and III)



Females

1. If your score is over 175, almost certainly Candida is a contributing factor to your health condition.
2. If your score is over 120, it is likely that Candida is causing some health issues.
3. If your score is between 60-120, Candida possibly contributes to your health but in a minor way.
4. A score less than 60 means that Candida is not causing a problem significant enough to treat.

Males

For males the score is downgraded a bit; above 100 puts you in category 1; 80-100 category 2; 50-80 category 3 and below 50 categorized as not of any concern.

We start treating females if above 120 and males if above 80.

Please refer to the Candida Diet for a recommended program.