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Clinical Reference // Appendix B - Microflora Imbalance Questionnaire


Microflora Imbalance Questionnaire


Section A: History


Circle the score to the right of each question when a response is “yes”, then total the circled numbers and write the total at the bottom of the section.


1.       Have you taken tetracycline (Sumycin®, Panmycin®, Vibramycin®, Minocin®, etc.) or other antibiotics for acne 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 for 2 months or longer, or for shorter periods, 4 or more times in a 1 year span?___ (20)

3.       Have you recently taken a broad spectrum antibiotic drug?___ (6)

4.       Have you taken prednisone, Decadron® or other cortisone-type drugs by mouth or inhalation…             

a.        for more than 2 weeks?___ (15)

b.       for 2 weeks or less?___ (6)

5.       If you have ever had thrush, athlete’s foot, ringworm, jock itch or other chronic fungus infections of the skin or nails, have such infections been…

a.        severe  or persistent?___ (20)

b.       mild or moderate?___ (10)

6.       Do you crave sugar/ sweets?___ (10)

7.       Do you crave breads?___ (10)

8.       Do you crave alcoholic beverages?___ (10)

Section A: Total Score _________


Section B: Secondary Indicators


For each symptom that is present, enter the appropriate number in the Point Score column:

·         If a symptom is occasional or mild

Score 3 points

·         If a symptom is frequent or moderately severe,

Score 6 points

·         If a symptom is severe and/or disabling,

Score 9 points


Total the scores for this section and record them at the end of this section.

1. Fatigue or lethargy __ 
2. Feeling of being “drained” __ 
3. Drowsiness _
4. Feeling “foggy” or “spacey” __                
5. Inability to make decisions  __ 
6. Inability to concentrate __ 
7. Poor memory __ 
8. Frequent mood swings __ 
9. Attacks of anxiety or crying __ 
10. Headaches __ 
11. Abdominal pain _
12. Constipation __ 
13. Diarrhea __ 
14. Bloating, belching or intestinal gas __ 
15. Indigestion or heartburn __ 
16. Chronic rashes or itching __ 
17. Psoriasis or recurrent hives _
18. Rectal itching __
 

Section B: Total Score ________


Section C: Minor Indicators


For each symptom that is present, enter the appropriate number in the Point Score column:

·         If a symptom is occasional or mild,

Score 1 point

·         If a symptom is frequent or moderately severe,

Score 3 points

·         If a symptom is severe and/or disabling,

Score 5 points


Total the scores for this section and record them at the end of this section.


1.Irritability or jitteriness  __

2. Dizziness/loss of balance __

3. Pressure above eyes or in ears…feeling of head swelling __

4. Tendency to bruise easily __

5. Food sensitivity or intolerance __

6. Dry mouth or throat __

7. Bad breath __

8. Foot, hair or body odor not relieved by washing __

9. Nasal congestion or post-nasal drip __

10. Nasal itching __

11. Sore throat __

12. Laryngitis, loss of voice __

13. Cough or recurrent bronchitis __

14. Burning or tearing of eyes __

15. Recurrent infections or fluid in ears __

16. Ear pain or deafness __

17. Numbness, burning or tingling __

18. Muscle aches __

19. Muscle weakness or paralysis __

20. Pain and/or swelling in joints __

21. Impotence  __

22. Urinary frequency, urgency or incontinence  __

23. Burning on urination __

24. Loss of sexual desire or feeling __


Section C: Total Score ________


Female-Specific History


1-3 circle the score if the answer is yes. 4-7 use scoring points below.

·         If a symptom is occasional or mild

Score 3 points

·         If a symptom is frequent or moderately severe,

Score 6 points

·         If a symptom is severe and/or disabling,

Score 9 points


Total the scores for this section and record at the bottom of this section.


1.       Have you at any time in your life, been bothered by persistent vaginitis or other problems affecting your reproductive organs? ___ (25)

2.       Have you been pregnant…

a.        2 or more times? ___ (5)

b.       1 time? ___ (3)

3.       Have you taken birth control pills for...

a.        more than 2 years? ___ (15)

b.       6 months to 2 years? ___ (6)

4.       Troublesome vaginal burning, itching or discharge __

5.       Endometriosis or infertility __

6.       Severe cramps and/or other menstrual irregularities __

7.       Premenstrual tension __


Combined Score

                

Section A _____ /116

               

Section B _____ /162

               

Section C _____ /120

               

Female specific _____ /81



Total Score _____



Women

Men

 

0-90

0-78

Unlikely an issue

90-229

78-196

Possibly present

229-479

196-398

Likely present