Patient Name: ________________________________________Date: ____________

 

 

CANDIDA  QUESTIONNAIRE

 

How many times did you take antibiotics during the past two years? _____________

How often do you eat sugar products? (chocolate/cookies/soft drink etc.) _________

Do you experience frequent sinus problems?  Yes ___  No ___

Do you experience irregular bowel movement (constipation/diarrhea)? Yes__ No __

Do you experience periodic depression/severe mood swings/fatigue? Yes ___ No __

How old is your house? _____ Is it near a __pond, __lake, or __river? Yes __ No __

When was the last time you had the air duct cleaned in your house? ______

Did you notice any mold presence in your house or place of work?  Yes ___ No ___

 

FEMALE  QUESTIONNAIRE

 

Last menstrual cycle date: _____________  Are you pregnant? ________

General period duration: ______ days;        General monthly cycle: ______ days

Details of last period: ________________________________________________

(scanty/excessive, clotting, color, cramping, mood swing, breast tenderness/distention)

 

Do you usually experience PMS?  Yes ___ No ___

If yes, what are the symptoms? _______________________________________

 

Were you on birth control pills/patches during the past 5 years?  Yes ___ No ___

If yes, how many years have you been on it? ______

How often do you have yeast infection?  ______

 

Did you do hysterectomy in the past? ____ If yes, when? _________ (ovary/uterus)

 

Do you have menopausal-like symptoms? ______

__ hot flashes  __ feeling hot frequently  __ irregular menstrual cycle 

__ sleeping disorders  __ mood changes  __severe fatigue  __vaginal dryness

__ low sex drive  __ difficult to lose weight

__ symptoms are controlled with medication _______________________________

 

Do you use hormone replacement therapy? ______

If yes, when did you start it? ________

List the hormones/dosage you are using ___________________________________

 

Do you have or suspect you have osteoporosis? ______

If yes, what medication/remedies are you using? _____________________________

 

Do you have thyroid disorder? ______

If yes, what medication/remedies are you using? ____________________________