Enter a number (from 0 – 5) after each of the following symptoms related to Candida. Zero (0) would represent “not present”; 5 would represent very severe expression of the symptom. What is your gender? Male Female 0 1 2 3 4 5 Vaginal discharge Frequent urination Bladder infections Sensitivity to smoke, perfume, insecticides, dry cleaning fumes, chemical fumes All symptoms increase in dampness or on muggy days Athlete’s foot, ringworm, “jock itch” Do you crave sugar? Do you crave bread? Do you crave wine or beer? Do you crave peanuts? Do you crave oranges? Do you crave grapes or raisins? Fatigue or lethargy Feeling “drained” Feeling “spacey” or “unreal” Depression Numbness Abdominal pain Constipation Diarrhea Bloating Low sex drive Cramps and/or menstrual irregularities Spots in front of eyes Irritability Inability to concentrate Mood swings Headaches Dizziness/loss of balance Itching Rashes Heartburn Indigestion Belching and/or passing gas Burning anus Bad breath Nasal congestion Burning or tearing of eyes Total Score on Short Questionnaire: (Treatment is recommended if females score above 20 or males are above 15) Please refer to the Candida Diet for a recommended program.