Please check each box that applies and tally your score at the end.
[50] Have you ever taken tetracyclines (Sumycin, Panmycin, Vibramycin, Minocin, etc) or other antibiotics for acne for 1 month or longer?
[50] 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 for shorter periods 4 or more times in a 1-years span?
[6] Have you taken a broad spectrum antibiotic drug - even for one period?
[25] Have you, at any time in your life, been bothered by persistent Prostatitis, Vaginitis, or other problems affecting your reproductive organs?
[5] Have you been pregnant 2 or more times?
[3] Have you been pregnant 1 time?
[15] Have you taken birth control pills for more than 2 years?
[8] Have you taken birth control pills 6 months to 2 years?
[30] Add 30 points if you noticed a general decline in your health around the time you started to take birth control pills.
[6] Have you taken birth control pills only 2 weeks or less?
[20] Does exposure to perfumes, insecticides, fabric ship odors, or other chemicals provoke moderate to severe symptoms?
[5] Does exposure to these produce symptoms in general?
[20] Are your symptoms worse on damp, muggy days or in moldy places?
[20] Have you had athlete's foot, ringworm, "jock itch" or other chronic fungus infections of the skin or nails that have been severe or persistent?
[10] Mild or moderate?
[10] Do you ever crave sugar?
[10] Do you crave breads?
[10] Do you crave alcoholic beverages?
[10] Does tobacco smoke really bother you?
Fatigue or lethargy
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Feeling of being "drained"
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Poor memory
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Feeling "spacey" or "unreal"
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Inability to make decisions
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Numbness, burning, or tingling
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Insomnia
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Muscle aches
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Muscle weakness or paralysis
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Pain and/or swelling in joints
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Abdominal pain
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Constipation
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Diarrhea
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Bloating, belching, or intestinal gas
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Troublesome vaginal burning, itching, or discharge
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Prostatitis
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Impotence
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Loss of sexual desire
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Drowsiness
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Irritability or jitteriness
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Incoordination
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Inability to concentrate
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Frequent mood swings
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Headaches
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Dizziness/ loss of balance
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Pressure above ears, feeling of head swelling
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Tendency to bruise easily
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Chronic rashes or itching
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Psoriasis or recurrent hives
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Indigestion or heartburn
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Food sensitivity or intolerance
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Mucus in stools
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Rectal itching
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Dry mouth or throat
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Rash or blisters in mouth
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Bad breath
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Foot, hair, or body odor not relieved by washing
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Nasal congestion or post nasal drip
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Nasal itching
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Sore throat
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Laryngitis, loss of voice
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Cough or recurrent bronchitis
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Pain or tightness in chest
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Wheezing or shortness of breath
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Urinary frequency, urgency, or incontinence
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Burning during urination
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Spots in front of eyes or erratic vision
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Burning or tearing of eyes
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Recurrent infections or fluid in ears
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Ear pain or deafness
[3] Occasional or mild
[6] Frequent or moderately severe
[9] Severe or disabling
Name
First Name
Last Name
Email
Do you think you have a yeast connected illness? Tell us more about what you are feeling.