Candida Questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

Name *

First

Last

Email *

Have you taken tetracycline or other antibiotics for acne for 1 month (or longer any time in your life)?

Have you at any time in your life taken broad spectrum antibiotics or other antibacterial medication for respiratory, urinary or other infections for two months or longer, or in shorter courses four or more times in a one-year period?

Have you taken a broad-spectrum antibiotic drug even in a single dose?

Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs?

Are you bothered by memory or concentration problems—do you sometimes feel spaced out?

Do you feel ‘‘sick all over’’ yet, in spite of visits to many different physicians, the causes haven’t been found?

Have you been pregnant..............Two or more times?

Have you taken birth control pills.......................For more than two years?

For six months to two years?

Have you taken steroids orally, by injection or inhalation? For more than two weeks? ........... For two weeks or less?

Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke . . . ……………Moderate to severe symptoms?..............Mild symptoms?

Does tobacco smoke really bother you?

Are your 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?

Do you crave sugar?

If a symptom is occasional or mild

If a symptom is frequent and/or moderately severe

If a symptom is severe and/or disabling

Fatigue or lethargy

Feeling of being ‘‘drained’’

Depression or manic depression

Headache

Muscle aches

Muscle weakness or paralysis

Pain and/or swelling in joints

Abdominal pain

Constipation and/or diarrhea

Bloating, belching or intestinal gas

Troublesome vaginal burning, itching or discharge

Prostatitis

Impotence

Loss of sexual desire or feeling

Endometriosis or infertility

Cramps and/or other menstrual irregularities

Premenstrual tension

Attacks of anxiety or crying

Cold hands or feet, low body temperature

Hypothyroidism

Shaking or irritable when hungry

Cystitis or interstitial cystitis

If a symptom is occasional or mild

If a symptom is frequent and/or moderately severe

If a symptom is severe and/or disabling

Drowsiness, including inappropriate drowsiness

Irritability

In-coordination

Frequent mood swings

Insomnia

Dizziness/loss of balance

Pressure above ears . . . feeling of head swelling

Sinus problems . . . tenderness of cheekbones or forehead

Tendency to bruise easily

Eczema, itching eyes

Psoriasis

Chronic hives (urticaria)

Indigestion or heartburn

Sensitivity to milk, wheat, corn or other common foods

Mucus in stools

Rectal itching

Dry mouth or throat

Mouth rashes, including ‘‘white’’ tongue

Bad breath

Foot, hair or body odor not relieved by washing

Nasal congestion or postnasal drip

Nasal itching

Sore throat

Laryngitis, loss of voice

Cough or recurrent bronchitis

Pain or tightness in chest

Wheezing or shortness of breath

Urinary frequency or urgency

Burning on urination

Spots in front of eyes or erratic vision

Burning or tearing eyes

Recurrent infections or fluid in ears

Ear pain or deafness

Comment