• Pre- Dysbiosis Questionnaire

    Pre- Dysbiosis Questionnaire

    Designed for adults to help evaluate whether dysbiosis—an imbalance of gut bacteria—may be contributing to health issues.

  • This questionnaire is designed for adults and the scoring system is not as appropriate for children. It lists factors in your medical history which are known to contribute to the disruption of normal healthy gastrointestinal bacteria, directly or indirectly promoting the overgrowth of yeast, fungi and other pathogens, (Section A), and symptoms commonly found in individuals with dysbiosis related illness (Section B and C).

    Filling out and scoring this questionnaire should help you and your physician evaluate the possible role of dysbiosis in contributing to your health problems. Yet will not provide and automatic “Yes” or “No” answer.

    Note: Dysbiosis refers to the condition where the normal healthy population of beneficial bacteria in the intestines had been disrupted, leaving it open to the overgrowth of yeast, fungi, parasites and potentially harmful strains of bacteria. This intestinal imbalance in turn adversely effects other important systems via toxic stress and interfering with nutrient absorption and utilizatio

  • SECTION A — HISTORY

    For every questions answered "Yes", the values are added and your Total score is recorded down below
  • 1. Have you taken tetracyclines or other antibiotics for acne or anything else for one month or longer?*
  • 2. Have you taken other antibiotics four or more times in a one‑year period?*
  • 3. Have you taken an antibiotic drug — even a single course?*
  • 4. Have you ever been bothered by recurrent or persistent prostatitis, vaginitis, or other reproductive organ problems?*
  • 5. Have you taken birth control pills:*
  • 6. Have you been pregnant:*
  • 7. Have you taken prednisone, Decadron, or other cortisone‑type drugs:*
  • 8. Does exposure to perfumes, insecticides, fabric shop odors, or chemicals provoke:*
  • 9. Are your symptoms worse on damp, muggy days or in moldy places?*
  • 10. Have you had athlete’s foot, ringworm, jock itch, or other chronic fungal infections?*
  • 10 a) If "Yes", has the infection been:
  • 11. Do you crave sugar?*
  • 12. Do you crave breads?*
  • 13. Do you crave alcoholic beverages?*
  • 14. Does tobacco smoke really bother you?*
  • 15. Have you ever had a parasitic infection, dysentery, or unexplained prolonged diarrhea?*
  • 16. Have you consumed chlorinated (tap) water for more than 3 months?*
  • 17. Do you consume non‑organic meat regularly?*
  • 18. Do you eat processed/packaged food regularly?*
  • 19. Do you drink alcohol or coffee daily?*
  • 20. Do you have or have you ever had an ulcer, colitis, Crohn’s disease, or diverticulitis?*

  • SECTION B — MAJOR SYMPTOMS

  • For each of your symptoms, enter the appropriate figure on the line following the question:

    • If this symprom does not apply to you= 0
    • If a symptom is occasional or mild = 3 points.
    • If a symptom is frequent &/or moderate = 6 points.
    • If a symptom is severe or disabling = 9 point. 

    Your Total score is recorded down below

  • Fatigue or lethargy*
  • Feeling of being drained*
  • Poor memory*
  • Feeling “spacey” or “unreal”*
  • Feeling “spacey” or “unreal”*
  • Numbness, burning, or tingling*
  • Muscle aches*
  • Muscle weakness or paralysis*
  • Pain and/or swelling in joints*
  • Abdominal pain*
  • Constipation*
  • Diarrhea*
  • Bloating*
  • Troublesome vaginal discharge*
  • Persistent vaginal burning or itching*
  • Prostatitis*
  • Impotence*
  • Loss of sexual desire*
  • Endometriosis*
  • Cramps and/or other menstrual irregularities*
  • Premenstrual tension*
  • Spots in front of eyes*
  • Erratic vision*
  • Eczema, dermatitis, psoriasis*

  • SECTION C — OTHER SYMPTOMS

  • For each of your symptoms, enter the appropriate figure on the line following that question.

    • If the symptom does not apply to you = 0pt
    • If the symptom is occasional or mild = 1pt
    • If the symptom is frequent &/or moderately severe = 2pt
    • If the symptom is sever &/or disabling = 3pt

    Your Total score is recorded down below

  • Drowsiness*
  • Irritability*
  • Poor coordination*
  • Inability to concentrate*
  • Frequent mood swings*
  • Headache*
  • Dizziness or loss of balance*
  • Pressure above ears / head swelling / tingling*
  • Itching*
  • Other rashes*
  • Heartburn*
  • Indigestion*
  • Belching & intestinal gas*
  • Mucus in stools*
  • Hemorrhoids*
  • Dry mouth*
  • Rash or blisters in mouth*
  • Bad breath*
  • Nasal congestion or discharge*
  • Joint swelling or arthritis*
  • Postnasal drip*
  • Nasal itching*
  • Sore or dry throat*
  • Cough*
  • Pain or tightness in chest*
  • Wheezing or shortness of breath*
  • Urgency or urinary frequency*
  • Burning on urination*
  • Failing vision*
  • Burning or tearing of eyes*
  • Recurrent infection or fluid in ears*
  • Ear pain or hearing loss*

  • The grand total score will help you and your physician decide if your health problems are dysbiosis related. Scores in women will run higher as 7 items in the
    questionnaire apply exclusively to women, while only 2 apply exclusively to men.


    Dysbiosis related health problems are almost certainly present in women with
    scores over 180, and in men with scores over 140.


    Dysbiosis related health problems are probably present in women with scores
    over 120 and in men with scores over 80.


    With scores of less than 60 in women and 40 in men, dysbiosis is unlikely to be
    contributing to your health challenges.

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