Candida Survey | Integrative Medicine Center of Western Colorado

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Candida Questionnaire

Score Sheet

This questionnaire is designed for adults and the scoring system isn't appropriate for children. It lists factors in your medical history which promote the growth of the common yeast, Candida Albicans (Section A), and symptoms commonly found in individuals with yeast-connected illness (Sections B and C).

For each “Yes” answer in Section A, check the box in that section. Your total score will calculate at the bottom of the section. Then move on to Sections B and C and complete as directed.

Filling out and scoring this questionnaire should help you and your provider evaluate the possible role of yeasts in contributing to your health problems, but it will not provide an automatic “Yes” or “No” answer.

Section A: HISTORY

Have you taken antibiotics for acne for 1 month (or longer)?

Yes

Have you taken other antibiotics for 2 months or longer, or in shorter course multiple times in a single year?

Yes

Have ever you taken a broad spectrum antibiotic?

Yes

Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs?

Yes

Have you been pregnant?

None

1 time

2 times or more

Have you taken birth control pills?

For 6 months to 2 years

More than 2 years

Have you taken steroids, such as prednisone or cortisone?

For 2 weeks or less

More than 2 weeks

Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke...

No reactions

Moderate to severe symptoms

Mild symptoms

Are your symptoms worse on damp, muggy days or in moldy places?

Yes

Have you had athlete’s foot, ringworm, “jock itch” or other chronic fungal infections of the skin or nails?

Mild to moderate symptoms

Severe or persistent symptoms

Do you crave sugar?

Yes

Do you crave breads?

Yes

Do you crave alcoholic beverages?

Yes

Does tobacco smoke really bother you?

Yes

Total Score for Section A

Candida Questionnaire

Section B: MAJOR SYMPTOMS

For each symptom which is present, enter the appropriate figure in the Point Score column:
If a symptom is occasional or mild......SCORE 3 points
If a symptom is frequent and/or moderately sever......SCORE 6 points
If a symptom is severe and/or disabling......SCORE 9 points

Fatigue or lethargy

Feeling of being “drained”

Poor memory

Feeling “spacey” or “unreal”

Inability to make decisions

Numbness, burning or tingling

Insomnia

Muscle aches

Muscle weakness or paralysis

Pain and/or swelling in joints

Abdominal pain

Constipation

Diarrhea

Bloating, belching or intestinal gas

Troublesome vaginal burning, itching or discharge

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 B Total

Candida Questionnaire

Section C: OTHER SYMPTOMS

For each symptom which is present, enter the appropriate figure in the Point Score column:
If a symptom is occasional or mild......SCORE 1 points
If a symptom is frequent and/or moderately sever......SCORE 2 points
If a symptom is severe and/or disabling......SCORE 3 points

Drowsiness

Irritability or jitteriness

Loss of coordination

Inability to concentrate

Frequent mood swings

Headaches

Dizziness or loss of balance

Pressure above ears or feeling of head swelling

Easy bruising

Chronic rashes or itching

Psoriasis or recurrent hives

Indigestion or heartburn

Food sensitivity or intolerance

Mucous in stools

Rectal itching

Dry mouth or throat

Rashes or blisters in mouth

Bad breath

Foot, hair or body odor not relieved by washing

Nasal congestion or post nasal drip

Nasal itching

Sore throat

Laryngitis or loss of voice

Cough or recurrent bronchitis

Pain or tightness in chest

Urinary frequency, urgency or incontinence

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

Section C Total

Total Score, Section A

Total Score, Section B

Total Score, Section C

GRAND TOTAL SCORE

(Total score from sections A, B and C)

The Grand Total Score will help us 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.

WOMEN
If you GRAND SCORE is:
< 60 then yeast connected health problems are not likely present >60 then yeast connected health problems are possibly present >120 then yeast connected health problems are probably present >180 then yeast connected health problems are very likely present

MEN
If you GRAND SCORE is:
< 40 then yeast connected health problems are not likely present >40 then yeast connected health problems are possibly present >90 then yeast connected health problems are probably present >140 then yeast connected health problems are very likely present

Comments

This field is for validation purposes and should be left unchanged.

Candida Questionnaire

Section A: HISTORY

Candida Questionnaire

Section B: MAJOR SYMPTOMS

Candida Questionnaire

Section C: OTHER SYMPTOMS

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