Candida Questionnaire

This questionnaire lists factors in your medical history which promotes the growth of common yeast, Candida albicans, and symptoms comonly found in individuals with yeast-connected illness. After you complete the questionnaire, you will be contacted about your results and the next steps to take. Your contact and health information will ONLY be used by a Caring for Candida Health and Wellness Consultant to analyze your Candida issues and contact you directly. Submitting the form does not obligate you in any way. We have the best interests of our clients at heart and want to provide you with the absolute best program available. Your honest and complete answers to the questions will allow us to provide you with exactly that.

Have you followed any other protocols to manage your candida in the past? Yes No
If so, what?
Have you taken tetracyclines (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics for acne for 1 month (or longer)? YesNo
Have you, at any time in your life, taken other "broad spectrum" antibiotics for respiratory, urinary or other infections (for 2 months or longer, or in shorter courses 4 or more times in a 1 year period)? YesNo
Have you taken a broad spectrum antibiotic drug - even in a single course? YesNo
Have you, at any time in your life, been bothered by persistent prostatits, vaginitis, or other problems affecting your reproductive organs? YesNo
Have you been pregnant... 2 or more times? 1 time? None of the above
Have you taken birth control pills for... more than 2 years? 6 months to 2 years? None of the above
Have you taken prednisone, Decardron, or other cortisone-type drugs by mouth or inhalation for... more than 2 weeks? 2 weeks or less? none of the above
Does exposure to perfumes, insecticides, fabric shop odors or other chemicals provoke... moderate to severe symptoms? mild symptoms? none of the above
Are your symptoms worse on damp, muggy days or in moldy places? YesNo
Have you had athlete's foot, ringworm, "jock itch" or other chronic fungous infections of the skin and nails that have been... severe or persistent mild or moderate none of the above
Do you crave sugar? YesNo
Do you crave breads? YesNo
Do you crave alcoholic beverages? YesNo
Does tobacco smoke REALLY bother you? YesNo
Please rate the severity of the following symptoms that you may experience:
Fatigue or lethargy Severe and/or disabling Frequent and/or moderately severe Occasional or mild None	Feeling of being "drained" Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Poor Memory Severe and/or disabling Frequent and/or moderately severe Occasional or mild None	Feeling "spacey" or "unreal" Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Inability to make decisions Severe and/or disabling Frequent and/or moderately severe Occasional or mild None	Numbness, burning or itching Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Insomnia Severe and/or disabling Frequent and/or moderately severe Occasional or mild None	Muscle aches Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Muscle weakness or paralysis Severe and/or disabling Frequent and/or moderatley severe Occasional or mild None	Pain and/or swelling in joints Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Abdominal pain Severe and/or disabling Frequent and/or moderately severe Occasional or mild None	Constipation Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Diarrhea Severe and/or disabling Frequent and/or moderately severe Occasional or mild None	Bloating, belching or intestinal gas Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Troublesome vaginal burning, itching or discharge Severe and/or disabling Frequent and/or moderately severe Occasional or mild None	Prostatitis Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Impotence Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Loss of sexual desire or feeling Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Endometriosis or infertility Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Cramps and/or other menstrual irregularities Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Premenstrual tension Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Attacks of anxiety or crying Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Cold hands or feet and/or chilliness Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Shaking or irritable when hungry Severe and/or disabling Frequent and/or moderately severe Occasional or mild None
Drowsiness Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Irritability or jitteriness Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Incoordination Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Inability to concentrate Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Frequent mood swings Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Headache Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Dizziness/Loss of balance Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Pressure above ears - feeling of head swelling Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Tendency to bruise easily Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Chronic rashes or itching Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Psoriasis or recurrent hives Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Indigestion or heartburn Severe and/or persistent Frequent and/or moderately severe Occasional and or mild None
Food sensitivity or intolerance Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Mucus in stools Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Rectal itching Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Dry mouth or throat Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Rash or blisters in mouth Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Bad breath Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Foot, hair or body odor not relieved by washing Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Nasal congestion or post nasal drip Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Nasal itching Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Sore throat Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Laryngitis, loss of voice Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Cough or recurrent bronchitis Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Pain or tightness in chest Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Wheezing or shortness of breath Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Urinary frequency, urgency, or incontinence Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Buring on Urination Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Spots in front of eyes or erratic vision Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
Buring or tearing of eyes Severe and/or persistent Frequent and/or moderately severe Occasional or mild None
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Gender: Male Female
Please read our disclaimer before continuing: The information provided by this website and Healthy Path Consultants is not intended to treat a disease or heal an illness, and should not take the place of a physician's care. It is our recommendation that, before implementing any program or incorporating any supplements, a qualified physician and/or health care professional should be consulted to have any and all symptoms and health concerns thoroughly diagnosed and treated. Your health status is a result of many components, which make you totally unique. The drugs you take for certain conditions may interfere with certain supplements. It is recommended that you consult your physician and/or health care professional and pharmacist for any potential interaction problems. The information contained here and in the consultation process is designed to help you understand how certain conditions may be created or worsened as a result of nutritional deficiencies. Any information provided is based on programs that have worked for us personally, our clients and the clients of many other Health and Wellness Consultants throughout the United States and Canada. Any recommendations made, should be fully researched by yourself, in conjunction with your physician and/or health care professional so that you understand how and when to use supplementation safely. We do not guarantee any health benefit beyond that of better general health. We offer this process to you because it has worked for us and others and because we have a heartfelt desire to help people get healthy!
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