Questionnaires
Below are a number of questionnaires that you can do to see if you have certain imbalances: Simply click on the name of the questionnaire you wish to do and the link will take you there. (links not active yet, please see below)
Adrenal fatigue
Allergies
Candida
Oestrogen deficiency
Oestrogen excess
Testosterone deficiency
Underactive Thyroid
Yeast overgrowth
Adrenal Questionnaire
Read each question carefully, and record the number next to a question if it applies to you. When you finish, add up the numbers you have recorded.
Do you experience fatigue? 3
Do you have allergies? 3
Do you have asthma? 3
Do you have recurrent infections? 3
Are you under severe emotional stress? 3
Do you suffer from chronic pain or physical stress? 3
Do you have low blood pressure? 2
Do you have a low pulse rate (<70/min with no exercise)? 2
Do you feel faint when you rise quickly? 2
Do you experience depressed moods? 2
Do you experience joint pain? 2
Do you have muscle pain? 2
Do you have low libido? 2
Do you have hair loss? 2
Do you have anxiety attacks? 2
TOTAL SCORE _______
<7 adrenal fatigue unlikely
7-12 adrenal fatigue possible
>12 adrenal fatigue very likely
Allergy Questionnaire
Read each question carefully, and record the number next to a question if it applies to you. When you finish, add up the numbers you have recorded.
Do you experience fatigue? 3
Do you have frequent headaches? 3
Do you experience sneezing, persistent runny or itchy nose? 4
Do you have frequent colds? 2
Do you experience dizziness? 4
Do you suffer from yearly sinus infections? 3
Do your eyes itch, water, get red or swell? 4
Do you have recurrent ear infections? 2
Do you have asthma, wheezing or chronic cough? 4
Do you have eczema, itchy skin, or hives? 3
Do you have indigestion, bloating, diarrhoea or constipation? 1
Do your symptoms worsen during a particular season? 4
Do your symptoms change when you go inside or outside? 3
Are your symptoms worse in parks or grassy areas? 4
Are your symptoms worse in your bedroom after going to bed? 2
Do you wake in the middle of the night with a blocked nose? 2
Are your symptoms worse in dusty areas? 4
Are your symptoms worse around animals? 2
Do you have any relatives with allergies? 2
Do you have mood swings or feel depressed for no reason? 1
Do you have recurrent yeast or fungal infections? 2
Do you develop symptoms after eating certain foods? 2
Do you sometimes feel stimulated or fatigued after meals? 2
Do you have dark circles under your eyes? 2
Do you have a crease across the bridge of your nose? 2
TOTAL SCORE _____
< 9 allergies are unlikely
9-12 allergies are possible
13-30 allergies are probable
> 30 allergies very likely
CANDIDA QUESTIONNAIRE Point Score
1. Have you taken antibiotics for acne for one month or longer? 35 _____
2. Have you ever taken antibiotics for two months or longer at a time or in short courses more than four times in a 12 month period? 35 _____
3. Have you ever taken an antibiotic? 6 _____
4. Have you ever been bothered by persistent prostatitis or vaginitis? 25 _____
5. Are you bothered by memory or concentration problems do you sometimes feel spaced out? 20 _____
6. Do you feel “sick all over” yet the cause hasn’t been found? 20 _____
7. Have you been pregnant? Once? 3 _____ More than once? 5 _____
8. Have you ever taken the birth control pill? For six months to two years? 8 _____ For more than two years? 15 _____
9. Have you ever taken an oral steroid medication like prednisone, steroids by injection or inhalation? For two weeks or less? 6 _____ For more than two weeks? 15 _____
10. Does exposure to perfumes, insecticides and other chemicals provoke: Mild symptoms? 5 _____ Moderate to severe symptoms? 20 _____
11. Are your symptoms worse on damp or muggy days? 20 _____
12. Have you ever had athletes foot, ringworm, jock itch or other chronic fungal infections of the skin or nails? Mild to moderate 10 _____ Severe or persistent 20 _____
13. Do you crave sugar? 10 _____
14. Does tobacco smoke really bother you? 10 _____
Total score for this section _____
Major Symptoms 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
1. Fatigue. _____
2. Feeling of being “drained”. _____
3. Depression. _____
4. Numbness, burning or tingling. _____
5. Headaches _____
6. Muscle aches. _____
7. Muscle weakness or paralysis. _____
8. Pain and/or swelling in joints. _____
9. Abdominal pain. _____
10. Constipation and/or diarrhoea _____
11. Bloating. _____
12. Persistent vaginal itch, burning or discharge. _____
13. Prostatitis. _____
14. Impotence. _____
15. Loss of sexual desire. _____
16. Endometriosis. _____
17. Cramps and/or other menstrual irregularities. _____
18. Premenstrual tension. _____
19. Attacks of anxiety. _____
20. Cold hands or feet, low body temperature. _____
21. Hypothyroidism _____
22. Shaking or irritability when hungry _____
23. Cystitis _____
Total score for this section _____
Other Symptoms 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
1. Drowsiness. _____
2. Irritability. _____
3. Lack of coordination. _____
4. Frequent mood swings. _____
5. Insomnia _____
6. Dizziness/loss of balance. _____
7. Feeling of head swelling and tingling. _____
8. Sinusitis _____
9. Tendency to bruise easily _____
10. Eczema _____
11. Psoriasis _____
12. Chronic hives (urticaria) _____
13. Indigestion _____
14. Food allergies _____
15. Mucus in stools _____
16. Rectal itching. _____
17. Dry mouth _____
18. Mouth rashes _____
19. Bad breath. _____
20. Foot, hair or body odour not relieved by washing _____
21. Nasal congestion or discharge. _____
22. Nasal itching. _____
23. Sore or dry throat. _____
24. Laryngitis _____
25. Cough. _____
26. Pain or tightness in chest. _____
27. Wheezing or shortness of breath. _____
28. Urinary urgency or frequency. _____
29. Burning on urination. _____
30. Failing vision. _____
31. Burning or tearing of eyes. _____
32. Recurrent infections or fluid in ears. _____
33. Ear pain or deafness. _____
Total Score for this Section _____
Overall Total Score _____
INTERPRETATION
>180 Yeast connected health problems are almost certainly present
120-180Yeast connected health problems are probably present
60-119Yeast connected health problems are possibly present
40-59 Yeast connected health problems are less likely to be present
Oestrogen Deficiency Questionnaire
Read each question carefully, and record the number next to a question if it applies to you. When you finish, add up the numbers you have recorded.
Do you have hot flashes? 4
Do you have night sweats? 4
Do you have vaginal dryness? 3
Do you have to pass urine more frequently than you used to? 2
Are you depressed? 2
Do you have difficulty sleeping? 3
Have you lost interest in sex? 2
Have your periods stopped? 4
TOTAL SCORE _____
< 5 oestrogen deficiency unlikely
5-9 oestrogen deficiency possible
> 9 oestrogen deficiency very likely
Oestrogen Dominance Questionnaire
Read each question carefully, and record the number next to a question if it applies to you. When you finish, add up the numbers you have recorded.
Do you experience premenstrual breast tenderness? 4
Do you have premenstrual mood swings? 4
Do you experience premenstrual fluid retention and weight gain? 4
Do you experience premenstrual headaches? 4
Do you experience migraines? 3
Do you experience severe menstrual cramps? 4
Do you have heavy periods with clotting? 3
Do you have irregular menstrual cycles? 3
Do you have uterine fibroids? 3
Do you have fibrocystic breast disease? 3
Do you have endometriosis? 2
Have you had infertility problems? 2
Have you had more than one miscarriage? 2
Do you experience joint pain? 1
Do you experience unusual muscle pain? 1
Do you have a decreased libido? 3
Do you have anxiety or panic attacks? 2
TOTAL SCORE ______
< 5 oestrogen dominance is unlikely
5-8 oestrogen dominance possible
9-20 oestrogen dominance probable
>20 oestrogen dominance is very likely
Testosterone Deficiency Questionnaire
Read each question carefully, and record the number next to a question if it applies to you. When you finish, add up the numbers you have recorded.
Do you experience fatigue? 2
Has your sense of drive and purpose decreased? 3
Do you lack initiative? 3
Are you less assertive? 3
Has your sense of well-being declined? 2
Do you have depressed moods? 2
Are you frequently irritable? 2
Has your self-confidence declined? 2
Do you find it difficult to set goals? 2
Do you have a difficult time making decisions? 2
Has your mental sharpness declined? 2
Has your stamina and endurance lessened? 2
Have you lost muscle mass, strength or tone? 4
Have you gained body fat around your waist? 2
Is your cholesterol elevated? 2
Has your libido decreased? 4
Has your sexual ability declined? 2
Do you find it difficult to obtain or maintain an erection? 2
Do you have sleep apnoea? 2
TOTAL SCORE _____
<7 testosterone deficiency unlikely
7-20 testosterone deficiency possible
> 20 testosterone deficiency very likely
Thyroid Questionnaire
Read each question carefully, and record the number next to a question if it applies to you. When you finish, add up the numbers you have recorded.
Do you experience fatigue? 4
Do you have elevated cholesterol? 4
Do you have difficulty losing weight? 2
Do you have cold hands and feet? 2
Are you sensitive to cold? 2
Do you have difficulty thinking? 2
Do you find it hard to concentrate? 2
Do you have poor short-term memory? 2
Are your moods depressed? 2
Are you experiencing hair loss? 2
Do you have fewer than one bowel movement a day? 2
Do you have dry skin? 2
Do you have itchy skin during the winter? 1
Do you experience fluid retention? 2
Do you have recurrent headaches? 1
Do you sleep restlessly? 1
Are you tired when you awaken? 2
Do you have afternoon fatigue? 2
Do you experienced tingling or numbness in your hands or feet? 2
Do you experience decreased sweating? 2
Have you had problems with infertility or miscarriages? 2
Do you have recurrent infections? 2
Do your muscles ache? 2
Do you have joint pain? 2
Do you have thinning of your eyebrows or eyelashes? 2
Is your tongue enlarged? 2
Is your skin pasty, puffy or pale? 2
Do you have decreased body hair? 2
Is your voice hoarse? 1
Do you have a pulse less than 60? 2
Do you have low blood pressure? 2
Is your average early-morning temperature less than 36.6? 4
Do you have sleep apnoea? 2
TOTAL SCORE _______
<11 unlikely you have low thyroid function
11-30 low thyroid function as a possibility
>30 low thyroid function is very likely
Yeast Overgrowth Questionnaire
Read each question carefully, and record the number next to a question if it applies to you. When you finish, add up the numbers you have recorded.
Do you experience fatigue? 3
Do you feel lethargic? 2
Do you have recurrent vaginal yeast infections? 4
Have you taken antibiotics multiple times during your life? 3
Do you have abdominal bloating, cramping or gas? 3
Do you have indigestion or heartburn? 2
Do you have flushing, headache, congestion or itchy skin after alcohol? 2
Do you crave sugar or bread products? 2
Do you have difficulty concentrating? 1
Do you have depressed moods? 1
Do you develop skin rashes or hives? 2
Do you have athletes foot? 4
Do you have jock itch? 4
Do you have fungal infections under your toenails or fingernails? 3
Do you have allergy symptoms? 1
Do you have recurrent respiratory infections? 1
Do you experience joint pain? 1
Do you experience muscle pain? 1
TOTAL SCORE _______
<10 yeast overgrowth unlikely
10-16 yeast overgrowth is a possibility
>16 yeast overgrowth is very likely