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Section A: History

Instructions: For each answer in section A, please select the one that best applies to your health history. Then move on to sections B and C, scoring as directed.

1. Have you taken tetracycline, doxycycline, penicillin, azithromycin, etc. or other antibiotic for acne for 1 month or longer?

Yes

2. Have you ever taken other "broad spectrum" antibiotics for urinary, respiratory or other infections for 2 months or longer? Or in shorter courses 4 or more times in a 1 year period?

Yes

3. Have you ever taken a "broad spectrum" antibiotic drug – even for one course?

Yes

4. Have you ever suffered from persistent prostatitis, vaginitis, or other problems that affect your reproductive organs?

Yes

5. Have you ever been pregnant?

1 time

2 or more times

6. Have you taken birth control pills?

For 6 months to 2 years

More than 2 years

7. Have you taken prednisone, or other oral steroid drugs?

For 2 weeks or less?

More than 2 weeks?

8. Does exposure to perfumes, insecticides, fabric softeners, candles, or other chemicals provoke symptoms?

Mild

Moderate to Severe

9. Are symptoms worse on damp, muggy days or in moldy places?

Yes

10. Have you had athlete’s foot, ringworm, "jock itch" or other chronic fungus infections of the skin or nails?

Mild to moderate symptoms?

Moderate to severe symptoms?

11. Do you crave sugar?

Yes

12. Do you crave bread or other foods high in carbohydrates?

Yes

13. Do you crave alcoholic beverages?

Yes

14. Does tobacco smoke significantly bother you?

Yes

Section B: Major Symptoms

Instructions: For each symptom that is present: rate as either mild, moderate, or severe.

If the question does not apply to you or the symptoms are not present, please skip the question and go on to the next one.

1. Fatigue or lethargy

Mild

Moderate

Severe

2. Feeling of being "drained"

Mild

Moderate

Severe

3. Poor memory

Mild

Moderate

Severe

4. Feeling "spacey" or "foggy"

Mild

Moderate

Severe

5. Depression

Mild

Moderate

Severe

6. Numbness, burning or tingling in arms and/or legs

Mild

Moderate

Severe

7. Insomnia

Mild

Moderate

Severe

8. Muscle aches

Mild

Moderate

Severe

9. Muscle weakness or paralysis

Mild

Moderate

Severe

10. Joint pain or swelling

Mild

Moderate

Severe

11. Abdominal pain

Mild

Moderate

Severe

12. Constipation

Mild

Moderate

Severe

13. Diarrhea

Mild

Moderate

Severe

14. Bloating, belching or intestinal gas

Mild

Moderate

Severe

15. Vaginal burning, itching or discharge

Mild

Moderate

Severe

16. Prostatitis

Mild

Moderate

Severe

17. Erectile dysfunction

Mild

Moderate

Severe

18. Loss of sexual desire

Mild

Moderate

Severe

19. Endometriosis or infertility

Mild

Moderate

Severe

20. Cramps and/or other menstrual irregularities

Mild

Moderate

Severe

21. Premenstrual mood swings

Mild

Moderate

Severe

22. Attacks of anxiety or crying

Mild

Moderate

Severe

23. Cold hands or feet and/or chilliness

Mild

Moderate

Severe

24. Shaking or irritable when hungry

Mild

Moderate

Severe

Section C: Other Symptoms

Instructions: For each symptom that is present: rate as either mild, moderate, or severe.

If the question does not apply to you or the symptoms are not present, please skip the question and go on to the next one.

1. Drowsiness

Mild

Moderate

Severe

2. Irritability or jitteriness

Mild

Moderate

Severe

3. Lack of coordination

Mild

Moderate

Severe

4. Inability to concentrate

Mild

Moderate

Severe

5. Frequent mood swings

Mild

Moderate

Severe

6. Headaches

Mild

Moderate

Severe

7. Dizziness or loss of balance

Mild

Moderate

Severe

8. Pressure above ears, feeling of head swelling/tingling

Mild

Moderate

Severe

9. Tendency to bruise easily

Mild

Moderate

Severe

10. Chronic rashes or itching

Mild

Moderate

Severe

11. Psoriasis or recurrent hives

Mild

Moderate

Severe

12. Indigestion or heartburn

Mild

Moderate

Severe

13. Food sensitivity or intolerance

Mild

Moderate

Severe

14. Mucus in stools

Mild

Moderate

Severe

15. Hemorrhoids or rectal itching

Mild

Moderate

Severe

16. Dry mouth or throat

Mild

Moderate

Severe

17. Rash or blisters in mouth

Mild

Moderate

Severe

18. Bad breath

Mild

Moderate

Severe

19. Foot, hair or body odor not relieved by washing

Mild

Moderate

Severe

20. Nasal congestion, discharge or post nasal drip

Mild

Moderate

Severe

21. Nasal itching

Mild

Moderate

Severe

22. Sore or dry throat

Mild

Moderate

Severe

23. Laryngitis (loss of voice), hoarse voice

Mild

Moderate

Severe

24. Cough or recurrent bronchitis

Mild

Moderate

Severe

25. Pain or tightness in chest

Mild

Moderate

Severe

26. Wheezing or shortness of breath

Mild

Moderate

Severe

27. Bladder frequency or urgency, loss of bladder control

Mild

Moderate

Severe

28. Burning with urination

Mild

Moderate

Severe

29. Spots in front of eyes or blurry vision

Mild

Moderate

Severe

30. Burning or tearing of eyes

Mild

Moderate

Severe

31. Recurrent ear infections or fluid in ears

Mild

Moderate

Severe

32. Ear pain or deafness

Mild

Moderate

Severe