Date
*
-
Year
-
Month
Day
Date
Name
*
First Name
Last Name
Email
*
example@example.com
SECTION A: History
Have you ever taken tetracyclines (Sumycin, Panmycino, Vibramycin, Minocin, etc) or other antibiotics for acne for one month (or longer)?
NO-0
YES-35
Have you ever, at any point in your life, taken other "broad spectrum" antibiotics for respiratory, urinary, or other infections, for two month or longer, or in shorter courses- four or more times in a one year period? Including: Reflex, ampicillin, amoxicillin, Ceclor, Bactrim, and Septra.
NO-0
YES-35
Have you taken a broad spectrum antibiotic drug, even a single course?
NO-0
YES-6
Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your reproductive organs?
NO-0
YES-25
Have you been pregnant two or more times?
NO-0
YES-5
Have you been pregnant one time?
NO-0
YES-3
Have you taken birth control pills for more than two years?
NO-0
YES-15
Have you taken birth control pills for six month to two years?
NO-0
YES-8
Have you taken Prednisone, Decadrong or other cortisone type drugs for more than two weeks?
NO-0
YES-15
Have you taken Prednisone, Decadrong or other cortisone type drugs for less than two weeks?
NO-0
YES-6
Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke moderate to severe symptoms?
NO-0
YES-20
Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke mild symptoms?
NO-0
YES-5
Are your symptoms worse on damp, muggy days or in moldy places?
NO-0
YES-20
Have you had athlete's foot, ringworm, "jock itch" or other chronic fungus infections of the skin or nails and have such infections been severe or persistent?
NO-0
YES-20
Have you had athlete's foot, ringworm, "jock itch" or other chronic fungus infections of the skin or nails? Have such infections been mild to moderate?
NO-0
YES-10
Do you crave sugar?
NO-0
YES-10
Do you crave breads?
NO-0
YES-10
Do you crave alcoholic beverages?
NO-0
YES-10
Does tobacco smoke really bother you?
NO-0
YES-10
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SECTION B: Major Symptoms
For each of your symptoms, enter the appropriate point score.
Not Present
3- occasional or mild
6- frequent or moderate
9- severe and disabling
fatigue or lethargy
feeling of being "drained"
poor memory
feeling "spacey"or"unreal"
depression
inability to make decisions
numbness, burning to tingling
muscle aches or weakness
pain &/or swelling in joints
abdominal pain
constipation
diarrhea
bloating, belching, or intestinal gas
troublesome vaginal burning, itching or discharge
persistent vaginal burning or itching
prostatitisis
impotence
loss of sexual desire or feeling
endometriosis or infertility
cramps &/or other menstrual irregularities
premenstrual tension
attacks of anxiety or crying
colds hands or feet &/or chilliness
shaking or irritable when hungry
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SECTION C: Other Symptoms
For each of your symptoms, enter the appropriate point score.
Not Present
1- occasional or mild
2- frequent or moderate
3- severe and disabling
drowsiness
irritability or jitteriness
inability to concentrate
lack of coordination
frequent mood swings
headaches
dizziness/loss of balance
pressure above ears, feeling of head swelling
tendency to bruise easily
chronic rashes or itching
numbness, tingling
indigestion or heartburn
food sensitivity or intolerance
mucus in stools
rectal itching
dry mouth or throat
rash or blisters in mouth
bad breath
foot, body or hair odor, not relieved by washing
nasal congestion or post nasal drip
nasal itching
sore throat
laryngitis, loss of voice
coach or recurrent bronchitis
pain or tightness in chest
wheezing or shortness of breath
urgency or urinary frequency
burning on urination
recurrent in sections or fluids in ears
ear pain or deafness
Submit
Should be Empty: