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Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com


The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Dysbiosis Questionnaire

PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.

     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 turn adversely affects other important organ systems via toxic stress and interfering wish nutrient absorption and utilization.

     This questionnaire is designed for adults only. The scoring system is not designed for children. The questionnaire will target factors in your medical and personal 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).

     Section A: For each question that applies to you, click on the Score Points that corresponds to the question.

     Section B and C: Follow the specific scoring system at the beginning of each section.

Date:
Name:
E-Mail:

WSN Acct. No.:



Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

Copyright 1999 Donna F. Smith


SECTION A: HISTORY
Score Point
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 one- year period?

20
3. Have you taken a broad spectrum anti-biotic 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?
For more than 2 years?
For 6 months to 2 years?
25
15
8
6. Have you been pregnant...  
2 or more times?
One time?
5
3
7. Have you taken Prednisone, Decadron or other cortisone type drugs...  
For more than 6 months?
For more than 2 weeks?
For 2 weeks or less?
25
15
6
8. Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke....  

Moderate to severe symptoms?
Mild symptoms?

List symptoms:

20
5

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

List symptoms:

20

10. Have you had athlete's foot, ring worm, "jock itch" or other chronic fungus infections of the skin or nails?
Have such infections been...

Yes
No

Severe or persistent?
Mild to moderate?

20
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 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 commercially raised flesh foods (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

Total Score, Section A

SECTION B: MAJOR SYMPTOMS

Score:
If a symptom is occasional or mild, score 3 points.
If a symptom is frequent and/or moderate, score 6 points.
If a symptom is severe or disabling, score 9 points.

Point Score

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

Total Score, Section B


SECTION C: OTHER SYMPTOMS

Score:
If a symptom is occasional or mild score 1 point.
If a symptom is frequent and/or moderately severe score 2 points.
If a symptom is severe and/or disabling score 3 points.


Point Score

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

Total Score, Section C

GRAND TOTAL SCORE:

Key to Scoring

Scores in women will run higher as seven items in the questionnaire apply exclusively to women, while only two apply exclusively to men.

Dysbiosis-related health problems are almost certainly present in women with Grand Total Scores over 180, and in men with scores over 140.

Dysbiosis-related health problems are probably present in women with Grand Total Scores over 120 and in men with scores over 80.

Dysbiosis is unlikely to be contributing to health challenges in women with Grand Total Scores of less than 60 and in men with Grand Total Scores of less than 40.