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Yeast questionnaire

Taken birth control pills 6 months to 2 years? Point score-8
Yeast Questionnaire
Developed by William G. Crook, M.D.
7. Have you taken prednisone, Decadron®, or other cortisone-type drugs by mouth or inhalation** for more than 2 weeks? This questionnaire lists factors in your medical
Point score-15
history that promote the growth of the common yeast,
Candida Albicans (Section A), and symptoms commonly

Point score-6
found in individuals with yeast-connected illness (Sections
B and C). For each yes answer in Section A, circle the Point

Score. Total your score, and record it at the end of the
section. Then move on to Sections B and C, and score as

8. Does exposure to perfumes, insecticides, fabric shop odors, directed.
or other chemicals provoke moderate to severe symptoms? Point score-20
Section A: History (circle only those that apply)
Point score-5
1. Have you taken tetracyclines (Sumycin®, Panmycin®,
Vibramycin®,Minocin®, etc.) or other antibiotics for acne for
1 month (or longer)?
Point score-50
9. Are your symptoms worse on damp, muggy days or in moldy places? Point score-20
2. Have you, at any time in your life, taken other "broad spectrum" antibiotics for respiratory, urinary or other 10. Have you had athlete’s foot, ringworm, "jock itch" or other infections for 2 months or longer, or for shorter periods 4 or chronic fungus infections of the skin or nails that have been Point score-20
Point score-50
Point score-10
3. Have you taken a broad spectrum antibiotic drug – even for one period? Point score-6
Point score-10
4. Have you, at any time in your life, been bothered by Point score-10
persistent prostatitis, vaginitis, or other problems affecting your reproductive organs? 13. Do you crave alcoholic beverages? Point score-10
Point score-25
14. Does tobacco smoke really bother you? 5. Have you been pregnant 2 or more times? Point score-10
Point score-5
Total Score, Section A _______
Pregnant 1 time? Point score-3
**The use of nasal or bronchial sprays containing cortisone
6. Have you taken birth control pills for more than 2 years? and/or other steroids promotes overgrowth in the
Point score-15
respiratory tract.
Section B: Major Symptoms
Section C: Other Symptoms*
For each symptom that is present, enter the appropriate
For each symptom that is present, enter the appropriate
number in the Point Score column:
number in the Point Score column:
If a symptom is occasional or mild, score 3 points.
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 frequent and/or moderately severe, score 6 points.
If a symptom is severe and/or disabling, score 9 points.
If a symptom is severe and/or persistent, score 9 points.
Total the score for this section, and record it at the end of
Total the score for this section and record it in the box at
this section.
the end of this section.
4. Feeling "spacey" or "unreal" 8. Pressure above ears, feeling of head swelling 14. Bloating, belching or intestinal gas 15. Troublesome vaginal burning, itching or discharge 19. Foot, hair or body odor not relieved by washing 20. Cramps and/or other menstrual irregularities 23. Cold hands or feet and/or chilliness Total Score, Section B
27. Urinary frequency, urgency or incontinence Fast and Free Home Test
29. Spots in front of eyes or erratic vision 31. Recurrent infections or fluid in ears morning, before you put ANYTHING in your *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.
up a bit of saliva, then spit it into the glass of water. . Total Score, Section C _______
Check the water every 15 minutes or so for up to one Total Score, Section B _______
hour. If you have a candida yeast infection, you will see strings (like legs) traveling down into the water from the saliva floating on the top, or Total Score, Section A _______
“cloudy” saliva will sink to the bottom of the glass, or cloudy specks will seem to be suspended in the water. If there are no strings and the saliva is Grand Total Score
still floating after at least one hour, you are probably candida yeast free. (add totals from Sections A, B and C) _______
If you have a bunch of threads or cloudiness, and especially if it develops The Grand Total Score will help you and your physician
decide if your health problems are yeast-connected. Scores

quickly, you can be pretty sure you have a serious case of candida for women will run higher, as 7 items in this questionnaire
infecting you. A few threads or light cloudiness indicate not as serious an apply exclusively to women, while only 2 apply exclusively
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
Kelowna, BC, V1Y 8K5
Tel: 250-762-5100
Yeast-connected health problems are possibly present in
women with scores over 60, and in men with scores over 40.
With scores less than 60 for women and 40 for men, yeast
are less apt to cause health problems.

Source: http://drpotter.net/articles/Form-Yeast%20Questionnaire.pdf

Yes

1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why? 2. When was your last medical check up? 3. Has there been any change in you general health in the past year? If yes, please 4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, PLEASE LIST 5. Do you have any allergies

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