History		Point Score
1	Have you taken tetracycline or other antibiotics for acne for one month or longer ?	25
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 short courses four or more times in a one year period ?	20
3	Have you ever taken a broad spectrum antibiotic( even a single course) ?	6
4	Have you at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problemsaffecting your reproductive organs ?	25
5	Have you been pregnant.... One Time ? Two Times ?	3 5
6	Have you taken birth control pills.... For six months to two years? For more than two years?	8 15
7	Have you taken prednisone or other cortisone-type drugs.... For two weeks or less ? For more than two weeks?	8 15
8	Does exposure to perfumes, insecticides, fabric shop odours, and other chemicals provoke... Mild symptoms? Moderate to severe symptoms?	5 20
9	Are your symptoms worse on dump, muggy days or In mouldy places ?	20
10	Have you had athlete's foot, ringworm, "jock itch", or other chronic infections of the skin or nails ? Mild or moderate ? Severe to persistent	10 20
11	Do you have crave sugar?	10
12	Do you have crave breads ?	10
13	Do you have alcoholic beverages ?	10
14	Does tobacco smoke really bother you ?	20
Total

Major Symptoms

For each of your symptoms, enter the appropriate figure in the point score column

• Score column
• If a symptom is occational or mild, score 3 points
• If a symptom is frquent and/or moderately severe, score 6 points
• If a symptom is severe and/or disabling score 9 points

	Point score
1	Fatigue or lethargy
2	Feeling or being "drained"
3	Poor memory
4	Feeling "spacey" or "unreal"
5	Depression
6	Numbness, burning or tingling
7	Muscle aches
8	Muscle weakness or paralysis
9	Pain and/or swelling joints
10	Abdominal pains
11	Constipation
12	Diahrreaa
13	Bloating
14	Persistent vaginal itch
15	Persistent vaginal burning
16	Prostatitis
17	Impotence
18	Loss of sexual desire
19	Endometriosis
20	Cramps and/or other menstural irregularities
21	Premenstural tension
22	Spots in front of eyes
23	Erratic vision
Total score of this section

Other Symptoms

For each of your symptoms, enter the appropriate figure in the point score column

• Score column
• If a symptom is occational or mild, score 1 points
• If a symptom is frquent and/or moderately severe, score 2 points
• If a symptom is severe and/or disabling score 3 points

	Point score
1	Drowsiness
2	Irritability
3	Incoordination
4	Inability to concentrate
5	Frequent mood swings
6	Headache
7	Dizziness/ loss of balance
8	Pressure above ears, feeling of head swelling and tingling
9	Itching
10	Other rashes
11	Heartburn
12	Indigestion
13	Belching and intestinal gas
14	Mucus in stool
15	Haemorrhoids
16	Dry mouth
17	Rash or blisters in mouth
18	Bad breath
19	Joint swelling or arthritis
20	Nasal congetion or discharge
21	Postnsal drip
22	Nasal Itching
23	Sore or dry throat
24	Cough
25	60Pain or tightness in chest
26	Wheezing or shortness of breath
27	Urinary urgency or frequency
28	Burning or urination
29	Falling vision
30	Burning or tearing of eyes
31	Recurrent infections or fluid in ears
32	Ear pain or deafness
Total score of this section
Total score of all three sections

Interpretation	Women	Men
Yeast connected health problems are almost certainly present	>180	>140
Yeast connected health problems are probably present	120-180	90-140
Yeast connected health problems are possibly present	60-119	40-89
Yeast connected health problems are less likely present	<60	<40