MEDICAL HISTORY HANOVER COLLEGE SPORTS MEDICINE Name___________________________________________________ Date_______________________________ Sport (s)__________________________________ Participation Year: In order to provide quality care it is important that all questions be answered completely. This information will be kept confidential. Do you have now or have you had in the pas
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Candida questionnaire and score sheetCandida Questionnaire
Name: _________________________________________________________________ Date _____________ This candida questionnaire is designed for adults and the scoring system isn't appropriate for children12 and under. It lists factors in your medical history which promote the growth of Candida Albicans(Section A), and symptoms commonly found in individuals with yeast-connected illness (Sections B andC).
For each "Yes" answer in Section A, circle the point score in that section. Record your total score in the box at the end of the section. Then move on to Sections B and C and score as directed.
Filling out and scoring this questionnaire should help you and your doctor evaluate the possible role ofCandida in contributing to your health problems. Yet it will not provide an automatic "Yes" or "No"answer.
Have you taken tetracyclines (Symycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics foracne 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 2 months or longer or in shorter courses 4 or more times in a 1-year period? Have you taken a broad spectrum antibiotic* -- even in a single course? (Including Keflex, ampicillin,amoxicillin, Ceclor, Bactrim, and Septra). Such antibiotics kill off "good germs" while they are killing off Have you, at anytime in your life, been bothered by persistent prostatitis, vaginitis, or other problems Have you taken birth control pills for more than 2 years? Have you taken Prednisone, Decadron or other cortisone-type drugs for more than 2 weeks? Does exposure to perfumes, insecticides, fabric shop odors, and other chemicals provoke moderate tosevere symptoms? Are your symptoms worse on damp, muggy days or in moldy places? Have you had athlete's foot, ring worm, jock itch, or other chronic fungus infections of the skin or nails? Have such infections been severe or persistent? (Point Score) Add up the total points in Section A
For each of your symptoms, enter the appropriate figure in the point score column: 3 points - for occasional or Mild
6 points - for frequent and/or Moderately Severe
9 points - for severe and/or Disabling
Add total score and record it in the box at the end of this section: 4. Feeling "spacey" or "unreal" 15. Persistent vaginal burning or itching 20. Cramps and/or other menstrual irregularities (Point Score) Add up the total points in Section B
For each of your symptoms, enter the appropriate figure in the point score column: 1 point for occasional or Mild
2 points for frequent and/or Moderately Severe
3 points for severe and/or Disabling
Add total score and record it in the box at the end of this section: 8. Pressure above ears, feeling of head swelling and tingling 31. Recurrent infections or fluid in ears (Point Score) Add up the total points in Section C
Add up the all the total scores in each sectionTotal Score, Section A GRAND TOTAL SCORE
The Grand Total Score will help you and Dr. Hardy 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.
If your score is:
Note: This test is not for diagnosing illness.
If you have a serious health problem consult with your health practitioner.
Brian N. Hardy, DC, LAc, CCN, DACBN
301 North 200 East
St. George, Utah 84770
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