Questionnaires

You, like all of our patients, know your own condition and symptoms better than anyone. The answers to detailed questionnaires provide Dr. Richards with valuable information about each patient's condition.

NOTE: It is suggested that you select/copy the text of the particular questionnaire you wish to take and place/paste that questionnaire text into a word processing program - then take the test from the copy printed from that program.

Food Allergy Questionnaire

Do you have delayed food allergies? Do you have or have your ever been told you have any of the following symptoms?

Please put check mark all that apply to you and two check marks if you experience that symptom often or quite strongly.

Musculoskeletal
Rheumatoid Arthritis
Osteoarthritis, generalized
Degenerative joint disease
Arthritis, allergic
Arthritis, allergic involving shoulder
Arthritis, allergic involving pelvic
Arthritis, allergic involving lower leg
Muscle or bone pain, migratory
Tendonitis, migratory
Fibromyalgia (muscle pain)
"Growing pains"
Stiffness or limitation of movement
Rheumatoid factor negative

Ear, Nose & Throat
Chronic serous otitis media
Chronic tubotympanic catarrh
Mucoid Otitis media "glue ear"
Dysfunction of eustachian tube fluid in ear
Chronic Sinus problems
Frequently clear your throat
Frequently sore throat
Sinus polyps
Nasal Polyps
Sinus Trouble
Allergic rhinitis, chronic stuffy nose
Canker sores in mouth
Bad breath, metallic taste in mouth
Hoarseness, intermittent
Dizziness
Allergy, unspecified
Thick post nasal drip

Gastrointestinal
Esophageal, gastroesophageal reflux
Gastritis: allergic, irritant
Vomiting
Colitis
Constipation
Irritable bowel syndrome
Diarrhea
Ulcerative Colitis
Heartburn
Bloating or hyperacidity
Colic in infants

Cardiovascular
Rapid or irregular heartbeat
Prolapsed mitral valve syndrome in healthy people
Edema of extremities
High blood pressure, especially in the young

Chest
Chronic cough
Tightness in chest
Asthma, intrinsic
Asthma, allergic unspecified
Bronchitis, chronic

Endocrine
Low blood sugar (hypoglycemia)
High blood sugar (hyperglycemia)
Cold feet (low thyroid)
Weight gain - no diet works

Genitourinary
Cystitis
Enuresis, bed wetting in children
Vaginal itching or discharge
Yeast infections, chronic
PMS, fluid retention, irritability, severe cramps

Dermatologic
Eczema intrinsic atopic
Dermatitis, adult and teenage acne
Acne Rosacea, red nose
Rashes from foods eaten
Psoriasis
Rash or hives urticaria
Urticaria dry or itchy skin

Neurologic
Migraine headaches - common
Cluster headaches
Tension or sinus headaches
Headaches
Depression
Chronic Fatigue or sluggishness
Anxiety or irritability
ADD w/Hyperactivity - restlessness
Learning disability -ADD
Behavior problems in children
Quick temper or impatient
Poor memory or comprehension
Mental confusion
Short attention span

Four or more check marks indicate that you may be experiencing Food Allergies. A more comprehensive assessment is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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Are you down because of blood Sugar Imbalances?

Because of the role which blood sugar plays in the function of the Central Nervous System, the symptoms of blood sugar imbalances are vast and varied. Below are listed just some of these symptoms.

Check any of the statements that apply to you:
Sudden anxiety associated with hunger
Profuse perspiration, clammy skin.
Confusion, disorientation.
Tingling sensation in hands.
Poor memory.
Dizziness.
Mild headaches.
Blurred or double vision.
Excessive, frequent urination.
Increased thirst and appetite.
Fatigue, drowsiness.
Craving for sweets.
Unintentional weight loss.
Very slow wound healing.
Lack of coordination.
Feeling shaky, jittery, tremors.

Three or more check marks indicate that you may be experiencing blood sugar imbalances. A more comprehensive assessment is strongly warranted and highly recommended.

Do you think you have this condition? If so, see our information on Consultations.

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Chronic Fatigue Syndrome Questionnaire

Note: we suggest that you select the text of this questionnaire and copy it to a word document so that you can answer the questions and determine your score.

 This symptom checklist cannot be used to diagnose Chronic Fatigue Syndrome unless other disorders have been ruled out by physical examination and appropriate laboratory tests.

___ 1. Fatigue (95%) - usually made worse by physical exercise

2. Cognitive function problems (80%)
___ a) attention deficit disorder
___ b) calculation difficulties
___ c) memory disturbance
___ d) spatial disorientation
___ e) frequently saying the wrong word

3. Psychological problems (80%)
___ a) depression
___ b) anxiety - which may include panic attacks
___ c) personality changes - usually a worsening of a previous tendency
___ d) emotional lability (mood swings)
___ e) psychosis

4. Other nervous system problems (75%)
___ a) sleep disturbance
___ b) headaches
___ c) changes in visual acuity
___ d) seizures
___ e) numb or tingling feelings
___ f) dysequilibrium
___ g) lightheadedness - feeling "spaced out"
___ h) frequent unusual nightmares
___ i) difficulty moving your tongue to speak
___ j) ringing in ears
___ k) paralysis
___ l) severe muscular weakness
___ m) blackouts
___ n) intolerance of bright lights
___ o) intolerance of alcohol
___ p) alteration of taste, smell and/or hearing
___ q) non-restorative sleep
___ r) decreased libido
___ s) twitching muscles ("benign fasciculations")

___ 5. Recurrent flu-like illnesses (75%) - often with chronic sore throat

___ 6. Painful lymph nodes especially on sides of neck and under the arms (60%)

___ 7. Severe nasal and other allergies often worsening of previous mild problem (40%)

___ 8. Weight change - usually gain (70%)

___ 9. Muscle and joint aches with tender "trigger points" or fibromyalgia

___ 10. Abdominal pain, diarrhea, nausea, intestinal gas - "irritable bowel syndrome" (50%)

___ 11. Low grade fevers or feeling hot often (70%)

___ 12. Night sweats (40%)

___ 13. Heart palpitations (40%)

___ 14. Severe premenstrual syndrome - PMS (70% women)

___ 15. Rash from herpes simplex or shingles (20%)

___ 16. Uncomfortable or recurrent urination - pain in prostate (20%)

17. Other symptoms seen in less than 10% of patients
___ a) rashes
___ b) hair loss
___ c) impotence
___ d) chest pain
___ e) dry eyes and mouth
___ f) cough
___ g) TMJ syndrome
___ h) mitral valve prolapse
___ i) frequent canker sores
___ j) cold hands & feet
___ k) serious heart rhythm disturbances
___ l) carpal tunnel syndrome
___ m) piriformis muscle syndrome causing sciatica
___ n) thyroid inflammation
___ o) various cancers (rare)
___ p) periodontal (gum) disease
___ q) endometriosis
___ r) easily getting out of breath ("dyspnea on exertion")
___ s) symptoms worsened by extremes of temperature
___ t) multiple sensitivities to medicine, food and other substances

With thanks to Daniel Peterson, MD, Paul Cheney, MD, PhD, and Jay A. Goldstein, MD

To Score: more than two positive answers on questions 1-5 plus more than four positive answers on questions 6-17 indicate a high probability that your symptoms may be due to chronic fatigue.

 Do you think you have this condition? If so, see our information on Consultations.

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Can you reduce your susceptibility to injury?

Check any of the statements that apply to you.

Do You Experience:
Fatigue.
Generalized muscle achiness.
Numbing or tingling sensation on lips, tongue, fingers and feet.
Localized pain, cramping, spasms or weakness.
Cramps or spasms in many muscles.
Muscles twitch and/or tremble (eyelids, thumb, calf muscle).
Muscle weakness.
Restless leg movements and cramps at night.
Hypermobility in joints.
Injure easily (strain or sprain).
Headaches.
Cannot fully straighten or extend legs and/or arms.
Decreased sensation in hands and feet.
Difficulty speaking, swallowing or breathing.
Back pain.

Two or more check marks indicate that you may be anding the significance of this screen susceptible to injuries. A more comprehensive assessment is strongly warranted and highly recommended.

Do you think you have this condition? If so, see our information on Consultations.

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Can you improve your intestinal health?

Check any of the following statements that apply to you.

Do You:
Take pain killers and/or anti-inflammatory medication (aspirin, cortisone, ibuprofen)?
Have a history of antibiotic use?
Experience gastrointestinal problems, i.e., ulcers, diverticulosis, irritable bowel, lactose intolerance, diabetes, colitis?
Have high blood fats (cholesterol)?
Eat less than 5 servings of fresh fruits vegetables and whole grains daily?
Eat small, frequent meals to avoid indigestion and bloating?
Experience abdominal discomfort and/or distention?
Experience belching, burping, bloating food repeats?
Experience flatulence?
Experience indigestion due to strong feelings, stress at home or at work?
Experience abdominal pain and/or cramps?
Experience relief from abdominal pain after a bowel movement?
Experience loose stool?
Experience persistent diarrhea?
Pass undigested food?
Experience diarrhea or loose stool when you eat milk, spicy foods and fruit?
Travel abroad or journey where food and water are contaminated?
Experience less than one bowel movement daily?
Experience hard, dry stool?
Experience constipation after consuming spicy, fatty, high fiber foods, excessive coffee?
Depend on laxatives (stool softeners, mineral oil, herbs)?
Experience frequent colds, flu and infections?
Experience bad breath?
Experience yeast infections/rashes (groin or genital, oral, skin)?
Experience disinterest in food and general lack of appetite?
Experience general lack of energy and are you tired, listless?

Two or more check marks indicate that your intestinal health may not be optimal. A more comprehensive assessment is strongly warranted and highly recommended.

Do you think you have this condition? If so, see our information on Consultations.

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Can you reduce the suffering caused by PMS?

Premenstrual Syndrome (PMS) is a variety of physical and psychological changes that some women experience before the beginning of their menstruation cycle. Many symptoms are attributed to this disorder and can be alleviated. Check any of the symptoms that apply to you. Consider 3 days to 2 weeks prior to menstruation.

Do You Experience:
Insomnia.
Abdominal bloating.
Breast tenderness, swelling.
Depression, irritability, nervousness.
Headaches.
Food cravings, binge eating.
Weight gain - water retention.
Back pain.
Sweating and flushing.
Diarrhea or constipation.
Clumsiness.
Breast lumps.
Suicidal.
Heart palpitations.
Nausea and/or vomiting.
Forgetfulness

Three or more check marks indicate that you may be suffering from PMS. A more comprehensive assessment is strongly warranted and highly recommended.

If you have 3 or more check marks, please complete the more detailed questionnaire that follows and return it to the RFHC for a more comprehensive work-up.
Do you think you have this condition? If so, see our information on Consultations.

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Menstrual Symptom Questionnaire

Note: select this test, copy and place in a word text document to print out a hard copy that you can fax to RFHC for scoring.


Name
Phone with area code

How long have you suffered from menstrual complaints:
_____ years? or ______months?

Have you had previous treatment? [ ] Yes [ ] No
If yes, please indicate type of treatment: [ ] Sedatives; [ ] Birth Control Pills;
[ ] Progesterone; [ ] Luprone; [ ] Anti-inflammatories (Motrin, e.g.);
[ ] Anti-depressants; [ ] Water pills (Pamprin, e.g.); [ ] Evening primrose oil;
[ ] Bromocriptine; [ ] Other, please specify_________________________

Duration of previous treatment:___________________________________
How long ago did you stop treatment, or are you still being treated?____________
My response to treatment was: [ ] Excellent; [ ] Good; [ ] No response; [ ] Worse

Please grade the following according to the symptoms of your LAST menstrual cycle only. Score as follows: 0 = none; 1 = mild (present, but does not interfere with activities; 2 = moderate (present, and interferes with activities, but not disabling); 3 = severe/disabling (unable to function)

Symptoms
___ Week before period ___ Week after period Nervous tension
___ Week before period ___ Week after period Mood swings
___ Week before period ___ Week after period Irritability
___ Week before period ___ Week after period Anxiety
___ Week before period ___ Week after period TOTAL

___ Week before period ___ Week after period Weight gain
___ Week before period ___ Week after period Swelling of extremities
___ Week before period ___ Week after period Breast tenderness
___ Week before period ___ Week after period Abdominal bloating
___ Week before period ___ Week after period TOTAL

___ Week before period ___ Week after period Headache
___ Week before period ___ Week after period Craving for sweets
___ Week before period ___ Week after period Increased appetite
___ Week before period ___ Week after period Heart pounding
___ Week before period ___ Week after period Fatigue
___ Week before period ___ Week after period Dizziness or Fainting
___ Week before period ___ Week after period TOTAL

___ Week before period ___ Week after period Depression
___ Week before period ___ Week after period Forgetfulness
___ Week before period ___ Week after period Crying
___ Week before period ___ Week after period Confusion
___ Week before period ___ Week after period Insomnia
___ Week before period ___ Week after period TOTAL

___ Week before period ___ Week after period GRAND TOTAL

Other Symptoms
___ Week before period ___ Week after period Oily skin
___ Week before period ___ Week after period Acne
___ Week before period ___ Week after period Menstrual cramps
___ Week before period ___ Week after period Menstrual backache

ADDITIONAL COMMENTS:





[Please complete and return to the RFHC for scoring and recommendations]

 Do you think you have this condition? If so, see our information on Consultations.

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Can you enjoy better health during menopause?

Menopause is the normal termination of the menses, occurring usually between the ages of 45 and 50. Many symptoms related to this condition can be alleviated. Check any of the symptoms that apply to you.

Do You Experience:
Irregular menstrual cycle.
Dry skin, hair, vagina.
Mood swings, irritability.
Depression, anxiety, nervousness.
Craving for sweets, binge eating.
Painful intercourse.
Sudden hot flashes.
Difficulty sleeping.
Mental fogginess.
Vaginal pain and/or itching.
Breast tenderness.
Easy bruising, loss of skin tone.
Low back and/or hip pain.
Abnormal growth of hair above lip.

Three or more check marks indicate that you might be experiencing menopause. A more comprehensive assessment is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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Can you reduce your susceptibility to muscle tension and cramps?

Check any of the following statements that apply to you.

Do You:
Tend to feel weak and tired most of the time?
Continuously use prescription drugs, particularly diuretics, pain medications, digitalis, hormone replacement therapy like estrogen, or chemotherapy?
Drink an excess of two 6 ounce cups of strong coffee daily?
Drink more than one glass of wine or alcoholic beverage daily?
Feel physically inactive due to lifestyle, disability or illness?
Have Chronic Fatigue Syndrome, Fibromyalgia, Epstein Barr Virus?
Experience muscle stiffness, soreness and tension especially in the neck and across the shoulders?
Experience muscle fatigue from exercise with a slow recovery?
Experience an inability to sweat when exercising?
Experience muscle aches and your muscles are tender the touch?
Experience muscle cramps and spasms?
Have a visible loss of muscle size?
Have a weak grip or loss of muscle strength?
Have increased joint mobility or greater than normal range of motion?
Stumble, trip, or fall easily?
Experience burning pain in the neck, shoulders, arms, back and legs?
Experience headaches?
Experience numbness, tingling or prickling sensations that run from the neck down the arm or from the lower back down the leg?
Experience a diminished feeling in finger and toes?
Experience an inability to feel vibrations?

Two or more check marks indicate that your muscle function may not be optimal. A more comprehensive assessment is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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Do you have a solid foundation for optimal health?

Check any of the following statements that apply to you.

Are You:
An adult female?
A teenager?
Retired or enjoying the golden years of life?
Pregnant?
A new mother?
Nursing a baby?
Very large or petite in physical size?
Experiencing heavy physical output in terms of work stress?
Experiencing heavy physical output in terms of athletic activity?
Experiencing emotional or other types of stress?
Recovering from surgery, wounds, burn or traumatic injuries?
Recovering from an extended hospital stay?
Experiencing any acute or chronic infections or illnesses?
Taking any medications or hormones?
Experiencing digestive problems?
Eating fast foods several times a week?
Frequently skipping meals (because of your busy schedule or any other reason)?
Dieting?
Drinking alcohol regularly?
Drinking coffee regularly?
Smoking cigarettes?
Exposed to air or water pollution?
Exposed to pesticides or work associated toxins?

One or more check marks indicate that you may not be receiving the nourishment needed to adequately provide a solid foundation for optimal health. A more comprehensive assessment is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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Is your health threatened by osteoperosis?

Recent food surveys demonstrate a majority American men, women, and children fail to consume adequate amounts of certain minerals including calcium, magnesium, iron, zinc, copper, and manganese. Considering the important role these minerals play in building maintaining strong and healthy bones, proper bone nourishment is essential for all Americans.

Check any condition that may apply to you:
Menopause.
Hysterectomy.
A family history of osteoporosis.
A thin, petite or small frame.
Pregnancy.
Breast feeding.
Allergy to, or avoidance of, milk or dairy products.
Regular use of drugs such as Dilantin, Prednisone, Lasix, Synthroid or other steroids.
Anti-ulcer medication.
Antacids containing aluminum.
Certain antibiotics.
Alcoholism.
Inadequate exercise or sedentary occupation.
Smoking.
Digestive problems.
Excess consumption of protein, soft drinks or caffeine.
Diet inadequate in calcium, magnesium, iron, zinc, manganese, and/or copper.
Have any of the following diseases -diabetes, thyroid disease, rheumatoid arthritis, kidney disease, hyper-parathyroidism or gum disease.

Two or more check marks indicate that you may be at risk for developing Osteoporosis. A more comprehensive assessment is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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Can you increase your resistance to cold, flu and infection?

Check any of the following statements that apply to you.

Do You:
Have a history of antibiotic use?
Continuously use prescription medication?
Drink an excess of two 6 ounce cups of strong coffee daily?
Drink more than one glass of wine or alcoholic beverage daily?
Smoke cigarettes or live with someone who continuously smokes?
Experience a general lack of appetite or disinterest in eating or food?
Catch colds easily?
Experience increasing irritability and fatigue?
Experience tiredness, weakness or chills with cold climates, changes in the weather sudden shifts in temperature?
Tend to get sick with seasonal changes?
Have dull, dry, thin hair that falls out easily?
Experience skin problems (scaly skin, rashes, itching, boils, acne)?
Have dark circles under your eyes or dark areas on your cheeks?
Have pale, brittle, spoon-shaped, ridged and/or misshapen nails?
Bruise easily?
Experience bleeding gums or nosebleeds?
Experience slow and/or incomplete healing of cut, sores or wounds?
Experience persistent stuffiness, congestion, cough or fatigue long after your cold or flu has run its course?
Experience mucus discharge from eyes, ears, nose or throat?
Experience pain, swelling, soreness or itching from eyes, ears, nose or throat?
Experience red, swollen lips or cracks at the corner of your mouth?
Experience a loss of or diminished sense of taste?
Have a red, smooth tongue with/or without cracks?
Experience increased tearing from eyes?
Experience poor vision at night?
Experience tingling, prickliness or numb sensations radiating down the arms to the fingers and/or the legs to the toes?
Experience swollen glands?
Have a low protein diet - very little to no animal products, inadequate amounts of whole grains and legumes as vegetarian protein?

Two or more check marks indicate your immune system may not be functioning optimally. A more comprehensive assessment is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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Are you experiencing pain unneccessarily?

Check any of the following statements that apply to you.

Do you experience mild, dull, nagging or periodic discomfort in your:
Neck?
Shoulders?
Elbows?
Hands?
Fingers?
Lowback?
Hips?
Knees?
Ankles?
Feet?
Experience menstrual pain?
Experience tension headaches?
Accept living with physical discomfort as a part of the aging process?
Frequently use aspirin or other pain relievers?
Experience environmental sensitivities to pollution?
Experience deficient, shallow or poor quality sleep?
Experience infrequent periods of rest, relaxation?
Eat fast food several times each week?
Regularly eat animal protein two times per day?
Drink less than 4 glasses of pure water each day?
Drink coffee, tea, alcohol or soda pop daily
Rarely exercise or enjoy other physical activity?

Two or more check marks indicate that you may be experiencing pain unnecessarily. A more comprehensive assessment is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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Is there a bettter way to shed those extra pounds and achieve your target weight?

Have you ever been on a diet to lose weight and had one or more of the following problems?

Check any of the statements that apply to you:
Lightheadedness upon standing
Heartbeat changes
Constipation
Joint or muscle pain
Intolerance to cold
Dry skin
Menstrual irregularities
Anemia
Prolonged sleep tendency.
Hair loss
Nervousness
Muscle loss
The "yo-yo" weight loss syndrome (as soon as you go oft the diet you gain back the fat at a rapid rate)

Four or more check marks indicate that you have experienced signs of a poor weight management program with adverse side effects. A more "balanced" approach, as well as a more comprehensive assessment, is strongly warranted and highly recommended.

 Do you think you have this condition? If so, see our information on Consultations.

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TMJ Questionnaire

1. I experience some pain, fatigue or discomfort when talking. True__ False__.
a. If true, my pain is __mild __moderate __severe

2. I am able to take care of my teeth and gums in a normal fashion without restriction and without pain, fatigue or discomfort. True__ False__.
a. If false, I have limited opening pain discomfort ___mild ___moderate ___severe

3. I can eat and chew anything I want without pain, discomfort or jaw tiredness. True__ False__.
a. If false, my pain/fatigue/discomfort is ___mild ___moderate ___severe

4. I enjoy a normal life and/or recreational activities without restriction. (For example, I can sing, cheer, laugh, play at amateur sports and hobbies, play musical instruments, etc.)True__ False__.
a. If false, I experience
___Increased discomfort with these activities
___Increased discomfort or the fear of aggravation limit the more energetic parts of my social life.
___I engage in very little social activity due to increased discomfort or pain.

5. I can yawn or open my mouth fully in a normal fashion, painlessly. True__ False__.
a. If false, there is
___Sometimes discomfort
___Always discomfort
___I am restricted by pain
___I am severely restricted by pain.

6. I am able to engage in all customary sexual activities and expressions without limitations and/or without causing headache, face or jaw pain. True__ False__.
a. If false,
___I sometimes experience headache, face, jaw pain or jaw fatigue
___It usually causes enough pain to markedly interfere with my enjoyment, willingness and satisfaction.
___I limit my activities due to limited mouth opening.
___I abstain from sexual activity because of the head, face or jaw pain it causes.

7. I sleep well in a normal fashion without any pain, medication, relaxants or sleeping pills. True__ False__.
a. If false,
___I sleep well with the use of pain pills, anti-inflammatories or medicinal sleeping aids.
___I fail to realize 6 hours of restful sleep even with the use of pills
___I fail to realize 4 hours of restful sleep even with the use of pills
___I fail to realize 2 hours of restful sleep even with the use of pills

8. I have been treated in the past for headaches, jaw pain or face pain. True__ False__.
a. If true,
___Some form of treatment completely controls my pain
___I get partial but significant relief through treatment
___I don't get much relief from any form of treatment
___There is no treatment to date which has helped me enough to make me want to continue.

9. I do not experience ringing in my ears. True__ False__.
a. If false,
___I experience some ringing, but it doesn't interfere with my sleep or my ability to perform my daily activities.
___The ringing in my ears interferes with my sleep and daily activities, but I can accomplish my goals and get enough sleep.
___I have marked impairment in my daily activities and an unacceptable loss of sleep due to the ringing in my ears.
___The ringing in my ears is incapacitating and it forces me to use a
masking device (white noise) to get any sleep.

10. I do not experience dizziness or lightheadedness. True__ False__.
a. If false,
___The dizziness does not interfere with my daily activities.
___The dizziness somewhat interferes with my daily activities but I can accomplish my goals
___The dizziness causes a marked impairment in my daily activities.
___I experience incapacitating dizziness.

If you have more than 2 positive answers, you probably need TMJ treatment.

 Do you think you have this condition? If so, see our information on Consultations.


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Dysbiosis Questionnaire

Note: we suggest that you select the text of this questionnaire and copy it to a word document so that you can answer the questions and determine your score.

Dysbiosis refers to the condition where the normal healthy population of beneficial bacteria in the intestines has been disrupted, leaving it open to the overgrowth of yeast, fungi, parasites, and potentially harmful strains of bacteria. This intestinal imbalance in tum adversely effects other important organ system via toxic stress and interfering with nutrient absorption and utilization.

This questionnaire is designed for adults and the scoring system isn't 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 yeasts, fungi and other pathogens, (Section A), and symptoms commonly found in individuals with dysbiosis related illness (Section B and C).

Please complete all 3 sections - otherwise, the scoring system is not accurate.

Filling out and scoring this questionnaire should help you and Dr Richards evaluate the possible role of dysbiosis in contributing to your health problems. Yet it will not provide an automatic "Yes" or "No" answer.

Section A: History
For each "Yes" answer in Section A, circle the Point Score after the question. Total your score and record it at the end of the questionnaire.

1. Have you taken tetracyclines (Sumycin, Panmycin, Vibramycin, Minocin, etc.) or other antibiotics for skin, acne or anything else for 1 month (or longer)? 25
2. Have you, at any time in your life, taken other "broad spectrum" antibiotics for respiratory, urinary or other infections in shorter courses 4 or more times in a 1 year period? 20
3. Have you taken a broad spectrum antibiotic drug - even a single course? 6
4. Have you, at any time in your life, been bothered by recurrent or persistent prostatitis, vaginitis or other problems affecting your reproductive organs? 25
5. Have you taken birth control pills
For more than 5 years? 25
For more than 2 years? 15
For 6 months to 2 years? 8
6. Have you been pregnant
2 or more times? 5
1 time? 3
7. Have your taken prednisone, Decadron or other cortisone type drugs
For more than 6 months? 25
For more than 2 weeks? 15
For 2 weeks or less? 6
8. Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke moderate to severe symptoms? 20
Mild symptoms? 5
List symptoms:
9. Are your symptoms worse on damp, muggy days or in moldy places? 20
List symptoms:
10. Have you had athlete's foot, ring worm "jock itch" or other chronic fungus infections of the skin or nails? (Y / N)
10a. Have such infections been
Severe or persistent? 20
Mild to moderate? 10
11. Do you crave sugar? 10
12. Do you crave breads? 10
13. Do you crave alcoholic beverages? 10
14. Does tobacco smoke really bother you? 10
15. Have you ever had a parasitic infection, dysentery or unexplained episode of prolonged diarrhea and or intestinal distress? 15
16. Have you ever consumed chlorinated (or chemically treated) drinking water for 3 or more months? 15
17. Do you consume supermarket meat (antibiotic fed) on a regular basis? 15
18. Do you eat processed foods regularly? 20
19. Do you drink alcohol or consume coffee daily? 20
20. Do you have or have you ever had an ulcer, colitis, crohn's disease or diverticulitis? 35
21. Were you breast fed? If no. 35
If yes, but for less than 3 months. 20

Total Score, Section A _____

Section B: Major Symptoms
For each of your symptoms, enter the appropriate figure after the question:
If a symptom is occasional and/or mild score 3 pts.
If a symptom is frequent and/or moderate score 6 pts.
If a symptom is severe and/or disabling score 9 pts.
Add total score and record it at the end of this section.

I . Fatigue or lethargy
2. Feeling of being "drained"
3. Poor memory
4. Feeling "spacey" or "unreal"
5. Depression
6. Numbness, burning or tingling
7. Muscle aches
8. Muscle weakness or paralysis
9. Pain and/or swelling in joints
10. Abdominal pain
11. Constipation
12. Diarrhea
13. Bloating
14. Troublesome vaginal discharge
15. Persistent vaginal burning or itching
16. Prostatitis
17. Impotence
18. Loss of sexual desire
19. Endometriosis
20. Cramps and/or other menstrual irregularities
21. Premenstrual tension
22. Spots in front of eyes
23. Erratic vision
24. Eczema, dermatitis, psoriasis

Total Score Section B ____

Section C: Other Symptoms
For each of your symptoms, enter the appropriate figure after the question:
If a symptom is occassional and/or mild score 3 pt
If a symptom is frequent and/or moderately severe score 6 pts
If a symptom is severe and/or disabling score 9 pis
Add total score and record it at the end of this section.

1. Drowsiness
2. Irritability or jitteriness
3. Incoordination
4. Inability to concentrate
5. Frequent mood swings
6. Headache
7. Dizziness/loss of balance
8. Pressure above ears - feeling of head swelling & tingling
9. Itching
10. Other rashes
11. Heartburn
12. Indigestion
13. Belching and intestinal gas
14. Mucus in stools
15. Hemorrhoids
16. Dry mouth
17. Rash or blisters in mouth
18. Bad breath
19. Nasal congestion or discharg
20. Joint swelling or arthritis
21. Postnasal drip
22. Nasal itching
23. Sore or dry throat
24. Cough
25. Pain or tightness in chest
26. Wheezing or shortness of breath
27. Urgency or urinary frequency
28. Burning on urination
29. Failing vision
30. Burning or tearing of eyes
31. Recurrent infection or fluid in ears
32. Ear pain or hearing loss

Total Score, Section C _____
Total Score, Section A _____
Total Score, Section B _____

GRAND TOTAL SCORE ______

The Grand Total Score will help you and Dr Richards 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.

 Do you think you have this condition? If so, see our information on Consultations.

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Candida Quiz

Note: we suggest that you select the text of this questionnaire and copy it to a word document so that you can answer the questions and determine your score.

 Predisposing History
For most questions, simply circle the appropriate answer ('Y' for yes, 'N' for no)

I. Have you ever taken tetracyclines (or other antibiotics) for acne for a period of 2 months or longer? Y N
2. Have you ever taken "broad spectrum" antibiotics* for respiratory, urinary or other infections for a period of 2 months or longer, or in shorter courses 4 or more times in a single year? Y N
*Including Keflex, ampicillin, amoxicillin, Ceclor, Bactrin and Septra
3. Have you taken prednisone, Decadron or other cortisone-type drugs? Y N
3b. If yes, have you taken them for more than 2 weeks? Y N
4. Does exposure to perfumes, insecticides, fabric store odors and other chemicals bother you? Y N
4b. If yes, please rate the symptoms from mild to severe (circle) 0 1 2 3 4 5 6 7 8 9 10
5. Do damp, muggy days or moldy places provoke symptoms? Y N
6. Have you had persistent athlete's foot, vaginal itch or other chronic
infections of the skin or nails? Y N
6b. If yes, please rate the infections from mild to severe or chronic 0 1 2 3 4 5 6 7 8 9 10
7. Do you crave sugar? Y N
8. Do you crave breads? Y N
9. Do you crave alcoholic beverages? Y N
10. Does tobacco smoke really bother you? Y N

Symptoms
For each of the symptoms listed below, please circle zero (0) if the symptom is not present but very mild, or circle any single number up to ten (10) for extremely severe. Circle only one number per symptom.

Please indicate only symptoms which are present NOW or the past few days.
0 1 2 3 4 5 6 7 8 9 10 . Poor memory
0 1 2 3 4 5 6 7 8 9 10 . Inability to concentrate
0 1 2 3 4 5 6 7 8 9 10 . Drowsiness
0 1 2 3 4 5 6 7 8 9 10 . Fatigue or lethargy
0 1 2 3 4 5 6 7 8 9 10 . Feeling of being "drained"
0 1 2 3 4 5 6 7 8 9 10 . Irritability or bitterness
0 1 2 3 4 5 6 7 8 9 10 . Frequent mood swings
0 1 2 3 4 5 6 7 8 9 10 . Depression
0 1 2 3 4 5 6 7 8 9 10 . Feeling "spacey" or "unreal"
0 1 2 3 4 5 6 7 8 9 10 . Poor coordination
0 1 2 3 4 5 6 7 8 9 10 . Dizziness/loss of balance
0 1 2 3 4 5 6 7 8 9 10 . Headache
0 1 2 3 4 5 6 7 8 9 10 . Pressure above ears feeling of head
0 1 2 3 4 5 6 7 8 9 10 . Spots in font of eyes
0 1 2 3 4 5 6 7 8 9 10 . Double vision
0 1 2 3 4 5 6 7 8 9 10 . Failing vision
0 1 2 3 4 5 6 7 8 9 10 . Burning or tearing of eyes
0 1 2 3 4 5 6 7 8 9 10 . Recurrent ear infections
0 1 2 3 4 5 6 7 8 9 10 . Muscle aches
0 1 2 3 4 5 6 7 8 9 10 . Muscle weakness
0 1 2 3 4 5 6 7 8 9 10 . Pain and/or swelling in joints
0 1 2 3 4 5 6 7 8 9 10 . Numbness over hands and feet
0 1 2 3 4 5 6 7 8 9 10 . Cold hands and feet
0 1 2 3 4 5 6 7 8 9 10 . Dry mouth
0 1 2 3 4 5 6 7 8 9 10 . Constant Thirst
0 1 2 3 4 5 6 7 8 9 10 . Sore throats with fever over 100 degrees
0 1 2 3 4 5 6 7 8 9 10 . Night sweats
0 1 2 3 4 5 6 7 8 9 10 . Rash or blisters in mouth
0 1 2 3 4 5 6 7 8 9 10 . Congestion when sweeping or dusting
0 1 2 3 4 5 6 7 8 9 10 . Sneezing when you mow the lawn
0 1 2 3 4 5 6 7 8 9 10 . Bad breath
0 1 2 3 4 5 6 7 8 9 10 . Nasal congestion or discharge
0 1 2 3 4 5 6 7 8 9 10 . Nasal itching
0 1 2 3 4 5 6 7 8 9 10 . Sore or dry throat
0 1 2 3 4 5 6 7 8 9 10 . Cough
0 1 2 3 4 5 6 7 8 9 10 . Pain or tightness in chest
0 1 2 3 4 5 6 7 8 9 10 . Wheezing or shortness of breach
0 1 2 3 4 5 6 7 8 9 10 . Heart palpitations
0 1 2 3 4 5 6 7 8 9 10 . Abdominal pain
0 1 2 3 4 5 6 7 8 9 10 . Constipation
0 1 2 3 4 5 6 7 8 9 10 . Diarrhea
0 1 2 3 4 5 6 7 8 9 10 . Gain weight easily
0 1 2 3 4 5 6 7 8 9 10 . Overweight
0 1 2 3 4 5 6 7 8 9 10 . Bloating
0 1 2 3 4 5 6 7 8 9 10 . Burning in your stomach after eating
0 1 2 3 4 5 6 7 8 9 10 . Indigestion
0 1 2 3 4 5 6 7 8 9 10 . Belching and intestinal gas
0 1 2 3 4 5 6 7 8 9 10 . Allergic reaction to goods (hives, rash, stomach problem every time you eat)
0 1 2 3 4 5 6 7 8 9 10 . Mucus in stools
0 1 2 3 4 5 6 7 8 9 10 . Hemorrhoids
0 1 2 3 4 5 6 7 8 9 10 . Skin rashes
0 1 2 3 4 5 6 7 8 9 10 . Bruise easily
0 1 2 3 4 5 6 7 8 9 10 . Rectal itching
0 1 2 3 4 5 6 7 8 9 10 . Urgency or urinary frequency
0 1 2 3 4 5 6 7 8 9 10 . Burning on urination
0 1 2 3 4 5 6 7 8 9 10 . Frequent urinary infections
0 1 2 3 4 5 6 7 8 9 10 . Frequent backache
0 1 2 3 4 5 6 7 8 9 10 . Dark circles under eyes
0 1 2 3 4 5 6 7 8 9 10 . Skin always pale
0 1 2 3 4 5 6 7 8 9 10 . Don't feel rested after sleep
0 1 2 3 4 5 6 7 8 9 10 . General health is good

Men Only
0 1 2 3 4 5 6 7 8 9 10 . Sores or irritation on penis or foreskin
0 1 2 3 4 5 6 7 8 9 10 . Persistent burning or itching of groin, scrotum or
0 1 2 3 4 5 6 7 8 9 10 . Impotence or inability to maintain
0 1 2 3 4 5 6 7 8 9 10 . Loss of sexual feeling
0 1 2 3 4 5 6 7 8 9 10 . Urethral drainage or discharge
Are you regularly exposed to insecticides? Y N
Are you exposed to high nitrogen fertilizers? Y N
If yes, please estimate how frequently
Are you exposed to toxic solvents such as toluene, xylene, acetone, etc.? Y N
If yes, would you estimate your exposure at greater than 2 years? Y N

Women Only
0 1 2 3 4 5 6 7 8 9 10 . Troublesome vaginal discharge
0 1 2 3 4 5 6 7 8 9 10 . Persistent vaginal burning
0 1 2 3 4 5 6 7 8 9 10 . Hard to get pregnant
0 1 2 3 4 5 6 7 8 9 10 . Loss of sexual feeling
0 1 2 3 4 5 6 7 8 9 10 . Dysmenorrhea (painful periods)
0 1 2 3 4 5 6 7 8 9 10 . Premenstrual tension
Have you, at any time in your life, been troubled by persistent vaginal problems or had 3 or more episodes of vaginitis in a year Y N
Have you ever been pregnant? Y N
If yes, how may times? ____
Have you taken birth control pills? Y N
If yes, have you taken them for more than 2 years? Y N


 Do you think you have this condition? If so, see our information on Consultations.

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Chronic Fatigue Syndrome Questionnaire

Note: we suggest that you select the text of this questionnaire and copy it to a word document so that you can answer the questions and determine your score.

 This symptom checklist cannot be used to diagnose Chronic Fatigue Syndrome unless other disorders have been ruled out by physical examination and appropriate laboratory tests.

___ 1. Fatigue (95%) - usually made worse by physical exercise

2. Cognitive function problems (80%)
___ a) attention deficit disorder
___ b) calculation difficulties
___ c) memory disturbance
___ d) spatial disorientation
___ e) frequently saying the wrong word

3. Psychological problems (80%)
___ a) depression
___ b) anxiety - which may include panic attacks
___ c) personality changes - usually a worsening of a previous tendency
___ d) emotional lability (mood swings)
___ e) psychosis

4. Other nervous system problems (75%)
___ a) sleep disturbance
___ b) headaches
___ c) changes in visual acuity
___ d) seizures
___ e) numb or tingling feelings
___ f) dysequilibrium
___ g) lightheadedness - feeling "spaced out"
___ h) frequent unusual nightmares
___ i) difficulty moving your tongue to speak
___ j) ringing in ears
___ k) paralysis
___ l) severe muscular weakness
___ m) blackouts
___ n) intolerance of bright lights
___ o) intolerance of alcohol
___ p) alteration of taste, smell and/or hearing
___ q) non-restorative sleep
___ r) decreased libido
___ s) twitching muscles ("benign fasciculations")

___ 5. Recurrent flu-like illnesses (75%) - often with chronic sore throat

___ 6. Painful lymph nodes especially on sides of neck and under the arms (60%)

___ 7. Severe nasal and other allergies often worsening of previous mild problem (40%)

___ 8. Weight change - usually gain (70%)

___ 9. Muscle and joint aches with tender "trigger points" or fibromyalgia

___ 10. Abdominal pain, diarrhea, nausea, intestinal gas - "irritable bowel syndrome" (50%)

___ 11. Low grade fevers or feeling hot often (70%)

___ 12. Night sweats (40%)

___ 13. Heart palpitations (40%)

___ 14. Severe premenstrual syndrome - PMS (70% women)

___ 15. Rash from herpes simplex or shingles (20%)

___ 16. Uncomfortable or recurrent urination - pain in prostate (20%)

17. Other symptoms seen in less than 10% of patients
___ a) rashes
___ b) hair loss
___ c) impotence
___ d) chest pain
___ e) dry eyes and mouth
___ f) cough
___ g) TMJ syndrome
___ h) mitral valve prolapse
___ i) frequent canker sores
___ j) cold hands & feet
___ k) serious heart rhythm disturbances
___ l) carpal tunnel syndrome
___ m) piriformis muscle syndrome causing sciatica
___ n) thyroid inflammation
___ o) various cancers (rare)
___ p) periodontal (gum) disease
___ q) endometriosis
___ r) easily getting out of breath ("dyspnea on exertion")
___ s) symptoms worsened by extremes of temperature
___ t) multiple sensitivities to medicine, food and other substances

With thanks to Daniel Peterson, MD, Paul Cheney, MD, PhD, and Jay A. Goldstein, MD

To Score: more than two positive answers on questions 1-5 plus more than four positive answers on questions 6-17 indicate a high probability that your symptoms may be due to chronic fatigue.

 Do you think you have this condition? If so, see our information on Consultations.

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