YEAST QUESTIONNAIRE

Yeast Questionnaire

Fatigue or lethargy ______

Feeling of being drained _____

Depression or manic depression _____

Pain and/or swelling in joints _____

Abdominal pain _____

Constipation and/or diarrhea _____

Bloating, belching or intestinal gas_____

Indigestion or heartburn _____

Cramps and/or menstrual irregularities ______

Premenstrual tension (PMS) ___

Sore throat _____

Recurrent infections or fluid in ears_____

Chronic hives ( urticaria ) _____

Cough or recurrent bronchitis _____

Nasal congestion or postnasal drip _____

Nasal itching _____

Laryngitis, loss of voice _____

Eczema, itching eyes _____

Sensitivity to milk, Wheat , Corn, or other common foods _____

Mucus in stools _____

Psoriasis ______

Cystitis or interstitial cystitis ________

In coordination ____

Pressure above ears/feeling of head swelling_____

Troublesome vaginal burning, itching or discharge _____

Rectal itching _____

Dry mouth or Throat _____

Mouth rashes, Including ¡§ white¡¨ tongue ____

Bad breath _____

Foot, hair or body odor not relieved by washing _____

Pain or tightness in chest _____

Wheezing or shortness of breath _____

Urinary frequency or urgency _____

Burning on urination _____

Ear pain or deafness ___

If check more than 5, please see chapter on Yeast Overgrowth. You may want to begin taking the Yeast Formula and probiotics.

Questionnaire - Yeast
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