Section A: History. 1. Have you taken tetracyline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotic for acne for 1 month or longer?
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1 CANDIDA QUESTIONNAIRE DR WENDY WELLS, NMD The total score will help you and your physician decide if your health problems are yeast-connected. ** Yeast-connected health problems are almost certainly present in women with scores over 130 and in men with scores over 140. ** 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, yeast is less apt to be the cause of health problems. Scores in women will run higher, as seven items in the questionnaire apply exclusively to women, while only two apply exclusively to men. Section A: History Instructions: For each yes answer in section A, Circle the Point Score in that section. Total your score and record it in the box at the end of the section. Then move on to Sections B and C, scoring as directed. 1. Have you taken tetracyline (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotic for acne for 1 month or longer? 2. Have you ever taken other "broad spectrum" antibiotics for urinary, respiratory or other infections for 2 months or longer, or in shorter courses 4 or more times in a 1 year period? Have you ever taken a "broad spectrum" antibiotic drug even for one period? 6 4. Have you ever been bothered by persistent prostatitis, vaginitis, or other problems that affect your reproductive organs? Have you ever been pregnant 2 or more times? 5-1 time? 3 6. Have you taken birth control pills for - more than 2 years? 15-6 months to 2 years? 8 7. Have you taken prednisone, Decadron or other cortisone type drugs for - more than 2 weeks? 15-2 weeks or less? 6 8. Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke - Moderate to severe symptoms? 20 - Mild symptoms? 5 9. Are symptoms worse on damp, muggy days or in moldy places? Have you had athlete s foot, ring worm, "jock itch" or other chronic fungous infections of the skin or nails? 20 - Moderate to severe symptoms? - - Mild to moderate symptoms? Do you crave sugar? Do you crave breads or other foods high in carbohydrates? 10
2 13. Do you crave alcoholic beverages? Does tobacco smoke really bother you? 10 Total Score Section A Section B: Major Symptoms Instructions: For each symptom that is present, enter the appropriate number 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. Total the score for this section and record it in the box at the end of this section. Point Score 1. Fatigue or lethargy 3 / 6 / 9 2. Feeling of being "drained" 3 / 6 / 9 3. Poor memory 3 / 6 / 9 4. Feeling "spacey" or "unreal" 3 / 6 / 9 5. Depression 3 / 6 / 9 6. Numbness, burning or tingling 3 / 6 / 9 7. Insomnia 3 / 6 / 9 8. Muscle aches 3 / 6 / 9 9. Muscle weakness or paralysis 3 / 6 / Joint pain or swelling 3 / 6 / Abdominal pain 3 / 6 / Constipation 3 / 6 / Diarrhea 3 / 6 / Bloating, belching or intestinal gas 3 / 6 / Troublesome vaginal burning, itching or discharge 3 / 6 / Prostatitis 3 / 6 / Impotence 3 / 6 / Loss of sexual desire or feeling 3 / 6 / 9
3 19. Endometriosis or infertility 3 / 6 / Cramps and/or other menstrual irregularities 3 / 6 / Premenstrual tension 3 / 6 / Attacks of anxiety or crying 3 / 6 / Cold hands or feet and/or chilliness 3 / 6 / Shaking or irritable when hungry 3 / 6 / 9 Total Score Section B Section C: Other Symptoms Instructions: For each symptom that is present, enter the appropriate number 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 persistent...score 9 points. Total the score for this section and record it in the box at the end of this section. Point Score 1. Drowsiness 3 / 6 / 9 2. Irritability or jitteryness 3 / 6 / 9 3. Incoordination 3 / 6 / 9 4. Inability to concentrate 3 / 6 / 9 5. Frequent mood swings 3 / 6 / 9 6. Headache 3 / 6 / 9 7. Dizziness/loss of balance 3 / 6 / 9 8. Pressure above ears, feeling of head swelling/tingling 3 / 6 / 9 9. Tendency to bruise easily 3 / 6 / Chronic rashes or itching 3 / 6 / Psoriasis or recurrent hives 3 / 6 / Indigestion or heartburn 3 / 6 / Food sensitivity or intolerance 3 / 6 / Mucus in stools 3 / 6 / 9
4 15. Hemorrhoids or rectal itching 3 / 6 / Dry Mouth or throat 3 / 6 / Rash or blisters in mouth 3 / 6 / Bad breath 3 / 6 / Foot, hair or body odor not relieved by washing 3 / 6 / Nasal congestion, discharge or post nasal drip 3 / 6 / Nasal itching 3 / 6 / Sore or dry throat 3 / 6 / Laryngitis, loss of voice 3 / 6 / Cough or recurrent bronchitis 3 / 6 / Pain or tightness in chest 3 / 6 / Wheezing or shortness of breath 3 / 6 / Urgency frequency, urgency or incontinence 3 / 6 / Burning on urination 3 / 6 / Spots in front of eyes or erratic vision 3 / 6 / Burning or tearing of eyes 3 / 6 / Recurrent infections or fluid in ears 3 / 6 / Ear pain or deafness 3 / 6 / 9 Total Score Section C
5 Total Score Section A Total Score Section B Total Score Section C Grand Total Score (add sections A, B & C) Test Scoring & Results The Grand Total Score will help you and your health care provider decide if your health problems are yeast-connected. Scores for woman will typically run higher. Yeast-connected health problems are almost certainly present in woman with scores over 180, and in men with scores over 140. Yeast-connected health problems are probably present in woman with scores over 120 and in men with scores over 90. Yeast-connected health problems are possibly present in woman with scores over 60 and in men with scores over 40. With scores less than 60 for woman and 40 for men, yeast are less apt to cause health problems. USE CONTACT FORM TO SEND RESULTS TO DR WENDY WELLS. TO SCHEDULE APPOINTMENT CALL
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ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: 403.243.8114 Fax: 403.212.0880 Full Name: Address: City: Province: Postal Code: Date of Birth (MM/DD/YYYY): Home Phone:
Symptom Questionnaire
Symptom Questionnaire The following questionnaire is a general assessment of your health developed by Dr Royal Lee D.D.S. Each grouping represents a particular area of your body that may be causing you
Mayflower Acupuncture LLC
Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this form as completely as you can. All information provided here will be held in strictest confidence.
ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac
ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac. 617-835-2512 Patient Information and Health History Date: Name: Date of Birth: Street: City: State: Zip: Phone: (H) (W) )
New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip
About You Pulley Chiropractic & Acupuncture, LLC Janine Pulley, D.C., L.Ac. 102 Peters Street, Suite 1, North Andover, MA 01845 P: 978-237-5106 * F: 978-420-4399 drjanine@pulleychiropractic.com * www.pulleychiropractic.com
PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS?
2 PHYSIOTHERAPIST Date of last visit MASSAGE THERAPIST Date of last visit SPECIALISTS Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS? WHAT IS THE PRIMARY REASON YOU ARE SEEKING CONSULTATION/TREATMENT?