For each “Yes” in section A, make a note of the point score indicated, then add these together to obtain the total for that section. Do the same for sections B and C. At the end of the questionnaire add these three figures together to obtain the Grand Total. SECTION A: MEDICAL HISTORY
1. Have you taken tetracyclines or other antibiotics for acne for one month (or longer)? Point
2. Have you, at any time in your life, taken other “broad spectrum” antibiotics for respiratory,
urinary or other infections (for two months or longer, or in shorter courses four or more times in a one-year period)? Point Score 35
3. Have you ever taken antibiotics, even for a single course? Point Score 6 4. Have you, at any time in your life, suffered from persistent prostatitis, vaginitis or other
problems affecting your reproductive organs? Point Score 25
5. Have you been pregnant? …. Two or more times, Point Score 5 ….Once, Point Score 3 6. Have you taken contraceptive pills? …. For more than two years, Point Score 15 ….For six
7. Have you taken or inhaled prednisone, Decadron® or other cortisone-type drugs? (The use
of nasal or bronchial sprays containing cortisone and/or other steroids aliments the proliferation of the fungus in the respiratory tract) ….For more than two weeks, Point Score 15 ….For two weeks or less, Point Score 6
8. Does exposure to perfumes, insecticides, fabric shop odours and other chemicals provoke
….moderate to severe symptoms? Point Score 20 ….mild symptoms? Point Score 5
9. Are your symptoms worse on damp, muggy days or in mouldy places? Point Score 20 10. Have you had athlete's foot, ring worm, “jock itch” or other chronic fungal infections of the
skin or nails? Have such infections been ….Severe or persistent? Point Score 20 ….Mild to moderate? Point Score 10
11. Do you crave sugar? Point Score 10 12. Do you crave breads? Point Score 10 13. Do you crave alcoholic beverages? Point Score 10 14. Does tobacco smoke really bother you? Point Score 10
Total score section A _____
SECTION B: MAJOR SYMPTOMS For each of your symptoms, make a note of the appropriate Point Score, as follows:
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 the scores to obtain the total for this section.
1. Fatigue or lethargy 2. Feeling of being “drained” 3. Poor memory 4. Feeling “spaced-out” or “unreal”
5. Inability to make decisions 6. Numbness, burning or tingling 7. Insomnia 8. Muscle aches 9. Muscle weakness or paralysis 10. Pain or swelling in joints 11. Abdominal pain 12. Constipation 13. Diarrhoea 14. Bloating, burping or intestinal gas 15. Troublesome vaginal burning, itching or discharge 16. Prostatitis 17. Impotence 18. Loss of sexual desire or feeling 19. Endometriosis or infertility 20. Cramps and/or other menstrual irregularities 21. Premenstrual tension 22. Attacks of anxiety or crying 23. Cold hands or feet 24. Shaking or irritable when hungry
Total score section B _____ SECTION C: OTHER SYMPTOMS N.B. While the symptoms in this section commonly occur in people with yeast-connected illnesses, they are also found in other individuals. For each of your symptoms, make a note of the appropriate Point Score, as follows:
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 the scores to obtain the total for this section.
1. Drowsiness 2. Irritability or jitteriness 3. Lack of coordination 4. Inability to concentrate 5. Frequent mood swings 6. Headaches 7. Dizziness / loss of balance 8. A feeling of pressure above the ears, or of head swelling 9. Tendency to bruise easily 10. Chronic rashes or itching 11. Recurrent psoriasis or hives 12. Indigestion or heartburn 13. Food sensitivity or intolerance 14. Mucus in stools 15. Rectal itching 16. Dry mouth or throat
17. Rash or blisters in mouth 18. Bad breath 19. Foot, hair or body odour not relieved by washing 20. Nasal congestion or post nasal drip 21. Nasal itching 22. Sore throat 23. Laryngitis, loss of voice 24. Cough or recurrent bronchitis 25. Pain or tightness in chest 26. Wheezing or shortness of breath 27. Urinary frequency or urgency, incontinence 28. Burning on urination 29. Spots in front of eyes or erratic vision 30. Burning or tearing of eyes 31. Recurrent infections or fluid in ears 32. Ear pain or deafness
Total score section C _____ Grand Total = Total Section A + Total Section B + Total Section C The Grand Total will help you and your therapist decide if your health problems are yeast-related. Note that scores for women will necessarily be higher, as seven items in the questionnaire apply exclusively to women, while only two 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 less than 40 in men, yeasts are less apt to cause
Rehabilitation Institute of Texas RIT Patient Initial Visit Information Sheet Patient Name: ____________________________ Age: _______ Gender: M FReferring Physician: _______________________ Primary Care Physician: ___________________ Reason for the visit: _______________________________________________________________ 1. When did your present problem start? _____________________
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