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Answering these questions and adding up the scores wil help you decide if yeasts contribute to your health problems. Yet
you wil not obtain an automatic “yes” or “no” answer.
For each “yes” answer in Section A, circle the Point score for each question or sub-question. Total your score and record it
in the space indicated at the end of the section. Then move on to Section B and C and score each section as instructed.
Add the total of your scores to get your Grand Total Score. ____________
Patient Name: _______________________________________________________ Date completed: ______________
SECTION A: HISTORY
Point Score
1. Have you ever taken tetracyclines (Sumycin®, Panmycin®, Vibramycin®, Minocin®, etc.) or other antibiotics fro acne for 1 month (or longer)? 2. 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)? 3. Have you taken a broad spectrum antibiotic drug*--even a single course? 4. Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems 6. Have you taken birth control pil s… 7. Have you taken prednisone, Decadron® or other cortisone-type drugs… 8. Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke… 9. Are your symptoms worse on damp, muggy days or in moldy places? 10. Have you had athlete’s foot, ring worm, “jock itch” or other chronic infections of the skin or nails? 14. Does tobacco smoke real y bother you? Total Score, Section A _________
*Including Keflex®, ampicil in, amoxicil in, Ceclor®, Bactrim® and Septra®. Such antibiotics kil off “good germs/bacteria” while they’re kil ing off those which cause infection. SECTION B: MAJOR SYMPTOMS

For each of your symptoms, 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 severe……………………. score 6 points If a symptom is severe and/or disabling………………………………….score 9 points Add total score and record in the space indicated at the end of this section. Point Score
13. Bloating, belching or intestinal gas 14. Troublesome vaginal burning, itching or discharge 15. Persistent vaginal burning or itching 20. Cramps and/or other menstrual irregularities 23. Cold hands or feet and/or chil iness Total Score, Section B __________

SECTION C: OTHER SYMPTOMS*

For each of your symptoms, enter the appropriate figure in the Point Score column: If a symptom is occasional or mild…………………………….score 1 point If a symptom is frequent and/or moderately severe……….….score 2 points If a symptom is severe and/or disabling………….…………….score 3 points Add total score and record it in the space provided at the end of this section. Point Score
8. Pressure above ears/feeling of head swel ing 19. Foot, body or hair odor not relieved by washing 29. Spots in front of eyes or erratic vision 31. Recurrent infections or fluid in ears Total Score, Section C _________
*While the symptoms in this section commonly occur in people with yeast connected il ness they are also found in other individuals. Total Score, Section A _________
Total Score, Section B _________
Total Score, Section C _________
GRAND TOTAL SCORE ____________


The Grand Total Score wil help you and your physician decide if your health problems are yeast connected.
Scores in women wil run higher as 7 items in the questionnaire apply exclusively to women, while only 2 apply
exclusively to men.
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 90.
Yeast-connected health problems are possibly present in women with scores over 60,
and in men with scores over 40.
With scores of less than 60 in women and 40 in men, yeasts are less apt to cause health problems.

Information reproduced with permission of Wil iam G. Crook, MD, Author of Yeast Connection.

Source: http://brenewed.com/main/wp-content/uploads/2011/06/Yeast-Questionnaire-Adult.pdf