Yeast Questionnaire Part 1 of 3
History

This questionnaire is confidential! The questions that you answer and the results of this test will only be seen by you and are not sent to our office nor will be reviewed by our office. Each response that you give will be assessed by our exclusive Health Evaluation Program and your results will be given at the conclusion of this test. Please feel free to contact our office if you have any questions or would like additional assistance with your results.

Part 1 of this test is a simple Yes or No section, Answer "yes" if the question applies to you...Answer "no" if it does not. Finally Click on Continue to part 2... to get to the next part of the test.

 

Type Your Full Name Type Your Gender
No
Yes
  
1. Have you ever taken tetracyclines (Symycin®, Vibramycin®, etc.) or other antibiotics for acne for one 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 for shorter cources 2 of more times in a 1 year period?

3. Have you ever taken a "broad spectrum antibiotic" - even in a single course?

4. Have you, at any time in your past, been botheres by persistant prostatitis, vaginitis or other problems affecting your reproductive organs?

5. Have you ever been Pregnant?
(If so, has it been 2 or more time? )
(If so, has it been only 1 time? )
6. Have you ever taken Birth Control Pills?
(If so, More than 2 years? )
(If so, 6 months to 2 years? )
7. Have you taken Prednisone®, Decadron® or other cortisone-type drugs?
(If so, More than 2 years? )
(If so, 6 months to 2 years? )
8. Does exposure to perfumes, insecticides, fabric shop odors, and other chemicals provoke symptoms?
(If so, Moderate to severe symptoms? )
(If so, Mild symptoms? )
9. Are your symptoms worse on damp, muggy days or in moldy places?
10. Have you had athletes foot, ring worm, jock itch or other chronic fungus infections of the skin or nails?
(If so, More than 2 years? )
(If so, 6 months to 2 years? )
11. Do you crave Sugar?
12. Do you crave Bread?
13. Do you crave Alcoholic beverages?
14. Does Tobacco smoke really bother you?