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Questionnaires / Assessment Tools 341
Yeast Questionnaire — Adult
Section c — other Symptoms
Enter the appropriate score for each symptom below.
If a symptom is occasional or mild
If a symptom is frequent or moderately severe
In Section A circle the score for each YES answer. For Sections If a symptom is severe or disabling
B and C score as indicated. Record total scores at the end of the questionnaire. Add the totals to get your GrAnd ToTAl ScorE.
Section A — History
2. Irritability or jitteriness. _________ 1. Have you taken tetracyclines (Sumycin, Panmycin, Vibra- mycin, Minocin, etc.) or other antibiotics for acne for one 2. Have you ever taken other “broad spectrum” antibiotics for urinary, respira- tory, or other infections for two months or longer, or in shorter courses four or more times in a 7. Dizziness/loss of balance . _________ 3. Have you ever taken a “broad spectrum” antibiotic drug? . 6 8. Pressure above ears, feeling of head tingling . _________ 4. Have you ever been bothered by persistent prostatitis, vaginitis, or other reproductive organ problems? .25 5. Have you been pregnant: two or more times? . 5 6. Have you taken birth control pills for more than two years? .15 13. Belching and intestinal gas . _________ 7. Have you taken prednisone, Decadron, or other cortisone- 8. Does exposure to perfumes, insecticides, fabric shop 17. Rash or blisters in mouth . _________ 9. Are symptoms worse on damp, muggy days or in moldy 19. Joint swelling or arthritis . _________ 10. Have you had athlete’s foot, ring worm, “jock itch,” or 20. Nasal congestion or discharge. _________ other chronic fungous infections of the skin or nails? 12. Do you crave breads? .1013. Do you crave alcoholic beverages? .10 14. Does tobacco smoke really bother you? .10
25. Pain or tightness in chest . _________ Section B — Major Symptoms
26. Wheezing or shortness of breath . _________ Enter the appropriate score for each symptom below. 27. Urgency or urinary frequency . _________ If a symptom is occasional or mild
If a symptom is frequent or moderately severe
If a symptom is severe or disabling
30. Burning or tearing of eyes . _________ 31. Recurrent infections or fluid in ears . _________ 2. Feeling of being “drained” . _________ 3. Poor memory . _________ 4. Feeling “spacey” or “unreal” . _________ Scores: Section A ______ Section B ______ Section C ______ 5. Depression . _________ 6. Numbness, burning, or tingling . _________ GrAnd ToTAl ScorE ______________
7. Muscle aches . _________ 8. Muscle weakness or paralysis . _________ The GrAnd ToTAl ScorE will help determine if your health problems are yeast
connected. Scores in women will run higher because more questions apply only 10. Abdominal pain . _________ 11. Constipation . _________ Yeast connected health problems are almost cErTAinlY prESEnT in women
with scores over 180, and in men with scores over 140.
12. Diarrhea . _________ 13. Bloating . _________ Yeast connected problems are proBABlY prESEnT in women with scores over
14. Troublesome vaginal discharge . _________ 15. Persistent vaginal burning or itching . _________ Yeast connected problems are poSSiBlY prESEnT in women with scores over
Scores less than 60 in women and 40 in men: yeasts are less apt to cause health 19. Endometriosis . _________ 20. Cramps and/or other menstrual irregularities . _________ 21. Premenstrual tension . _________ 22. Spots in front of eyes . _________ 23. Erratic vision . _________ 342 Questionnaires / Assessment Tools
Yeast Questionnaire — children
11. Has your child been labeled “hyperactive”? (Score 10 if mild, 20 if Circle the appropriate point score for questions you answer “yes.” Total your score and 12. Is your child bothered by learning problems (even though his early record it in the box at the end of the questionnaire.
1. During the two years before your child was born, were you both- 13. Does your child have a short attention span? ered by recurrent vaginitis, menstrual irregularities, premenstrual tension, fatigue, headache, depression, digestive disorders, or “feel-ing bad all over”? 14. Is your child persistently irritable, unhappy, and hard to please? 2. Was your child bothered by thrush? (Score 10 if mild, 20 if severe 15. Has your child been bothered by persistent or recurrent digestive problems, including constipation, diarrhea, bloating, excessive gas? (Score 10 if mild, 20 if moderate, 30 if severe.) 3. Was your child bothered by frequent diaper rashes in infancy? (Score 10 if mild, 20 if severe or persistent.) 16. Has your child been bothered by persistent nasal congestion, 4. During infancy, was your child bothered by colic and irritability lasting over 3 months? (Score 10 if mild, 20 if moderate or severe.) 17. Is your child unusually tired or unhappy or depressed? (Score 10 if 5. Are your child’s symptoms worse on damp days or in damp or 18. Has your child been bothered by recurrent headaches, abdominal pain, or muscle aches? (Score 10 if mild, 20 if severe.) 6. Has your child been bothered by recurrent or persistent “athlete’s foot” or chronic fungous infections of his skin or nails? 7. Has your child been bothered by recurrent hives, eczema, or other 20. Do you feel that your child isn’t well, yet diagnostic tests and stud- GRAND TOTAL SCORE
(A) 4 or more courses of antibiotic drugs during the past year? Or
has he received continuous “prophy-lactic” courses of antibiotic Yeasts POSSIBLY play a role in causing health problems in children with . 60
(B) 8 or more courses of “broad-spectrum” antibiotics (i.e. Amoxicil-
Yeasts proBABlY play a role in causing health problems in children with
lin, Keflex, Septra, Bactrim, or Ceclor) during the past 3 years? Yeasts AlMoST cErTAinlY play a role in causing health problems in
children with scores of 140 or more.
9. Has your child experienced recurrent ear problems? Copyright 1984, William G. Crook, M.D.
10. Has your child had tubes inserted in his ears?

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