Rate Your Health

     The following is a questionnaire titled "RATE YOUR HEALTH QUIZ" developed by Dr. Crook and published in his book THE YEAST SYNDROME.

     It is used as an assessment questionnaire to determine if you have Candida (fungus) overgrowth. You may print out this form and then fill it out and fax it to East-West Clinic if you have questions, or just e-mail us your total score, and we can answer questions you may have on Candida.

YOUR NAME:
DATE:

FOR ADULTS AND TEENAGERS

For each TRUE or YES answer, check the box.

Have you suffered with:
Frequent infections or constant skin problems? Have you taken antibiotics or steroid medications such as cortisone or prednisone, often or for long periods?
Feelings of fatigue, being drained of energy drowsiness? Do you feel these symptoms as well on damp muggy days, or when in moldy places such as basements?
Feelings of anxiety, irritability insomnia? Cravings for sugary foods, breads, alcoholic beverages?
Food sensitivities, allergy reactions? Digestion problems: bloating, heartburn, constipation, bad breath? Being bothered by perfumes, chemical fumes, tobacco smoke?
Feeling "spacy " or "unreal "? Difficulty in concentrating?
Poor coordination, muscle weakness, painful or swollen joints?
Mood swings, depression, or loss of sexual feelings?
Dry mouth or throat, nose congestion, or drainage?
Pain in the chest, shortness or breath, dizziness? Easy bruising?
Frustration of going from doctor to doctor, never getting your health completely well? Being told that your symptoms were "mental or "psychological or "Psychosomatic"?

FOR WOMEN ONLY

For each TRUE or YES answer, check the box.

Have you suffered with:
Vaginal burning, itching, discharge, infections? Urinary problems?
A difficult time getting pregnant? Been pregnant two or more times? Taken birth control pills?
Premenstrual symptoms: moodiness, fluid loading, tension? Irregular cycles? Menstrual problems? Sexual problems?

ESPECIALLY FOR CHILDREN


Frequent infections, particularly of the ears, tonsils, bronchitis? History of frequent diaper rash?
Continuous nasal congestion or drainage? Dark circle under the eyes? Periods of hyperactivity? Poor attention span?


Your Total:

Compare your total to the below assessment chart.


Contact Us

5770 W. Bald Eagle Blvd., White Bear Lake, MN 55110
Telephone and Fax: (651) 429-9595

E-mail East-West Clinic

© 1997 - 2004 East-West Clinic. All rights reserved.
Last Updated November 25, 2004