Yeast questionnaire.doc

christinestraley@gmail.com ~ www.rootedinnutrition.com Name: ________________________________ Date: _________________________ Section A:For each “yes” answer in section a put a check mark _____Have you taken tetracycline’s (Sumycin, Panmycin, Vibramycin, Minocin, and so forth) or other antibiotics for the acne for one month (or longer)?_____Have you, at any time in your life, taken other “broad-spectrum” antibiotics for respiratory, urinary, or other infections (for two months or longer, or in shorter courses four or more times in a one-year period)?_____Have you taken a broad-spectrum antibiotic drug even a single dose (Keflex, ampicillin, amoxicillin, Ceclor, Bactrim, and Septra)_____Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your reproductive organs?_____Have you been pregnant two or more times?_____Have you been pregnant one time?_____Have you taken birth control pills for more than two years?_____For six months to two years?_____Have you taken prednisone, Decadron, or other cortisone-type drugs for more than two weeks? _____Does exposure to perfumes, insecticides, fabric shop odors, and other chemicals provoke: _____Moderate to severe symptoms?_____Mild Symptoms? _____Are your symptoms worse on damp, muggy days or in moldy places?_____Have you had athlete’s foot, ringworm “jock itch,” or other chronic fungus infections of the skin or nails? Have such infections been :_____Severe or persistent? _____Do you crave sugar?_____Do you crave bread?_____Do you crave alcoholic drinks?_____Does tobacco smoke really bother you? Section B: Major SymptomsFor each of your symptoms, enter the appropriate figure in the points score section: If symptom is occasional or mild Score 3 PointsIf symptom is frequent and or moderately severe score 6 pointsIf a symptom is severe and or disabling score 9 points Fatigue or lethargy ___Feeling of being “drained” ___Poor memory ___Feeling “spacey” or “unreal” ___Depression ___Inability to make decision ___Numbness, burning, or tingling ___Muscle aches or weakness ___Pain and or swelling in joints ___Abdominal pain ___ Constipation ___Diarrhea ___Bloating, belching, or intestinal gas ___Troublesome vaginal burning, itching or discharge ___Persistent vaginal burning or itching ___Prostatitis ___Impotence ___Loss of sexual desire or feeling ___Endometriosis or infertility ___Cramps and /or other menstrual irregularities ___Premenstrual tension ___Attacks of anxiety or crying ___Cold hands or feet and or chilliness ___Shaking or irritable when hungry _________ Section C: Other SymptomsFor each of your symptoms, enter the appropriate figure in the points score section: If symptom is occasional or mild Score 1 PointsIf symptom is frequent and or moderately severe score 2 pointsIf a symptom is severe and or disabling score 3 points Drowsiness ____Irritability or jitteriness ___Lack of coordination ___Inability to concentrate ___Frequent mood swings ___Headaches ___Dizziness/loss of balance ___Pressure above ears, feeling of head swelling ___Tendency to bruise easily ___Chronic rashes or itching ___Numbness, tingling ___Indigestion or heartburn ___Food sensitivity or intolerance ___Mucus in stools ___Rectal Itching ___Dry mouth or throat ___ Rash or blister in mouth ___ Bad Breath ___Foot, body, or hair odor not relieved by washing ____Nasal congestion or postnasal drip ____Nasal itching ___Sore throat ___Laryngitis, loss of voice ___Cough or recurrent bronchitis ___Pain or tightness in chest ___Wheezing or shortness of breath ___Urgency or urinary frequency ___Burning on urination ___Spots in front of eyes or erratic vision ___Burning or tearing of eyes ___Recurrent infections or fluid in ears ___Ear pain or deafness ___ Taken From: The Body Ecology Diet by Donna Gates with Linda Schatz

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