Is yeast bothering you? Check it out! Adult1.- Have you taken antibiotics repeatedly or in a prolonged period of time?YesNo2.- Have you suffered from recurrent vaginal, prostate or urinary infections?YesNo3.- Do you feel sick all over your body without any reason found?YesNo4.- Do you suffered from hormone disturbances (eg. PMS, menstrual irregularities, sexual dysfunction, sugar craving, low body temperature or fatigue)?YesNo5.- Are you unusually sensitive to tobacco smoke, perfume, colognes and other chemical odors?YesNo6.- Are memory or concentration problems bothering you?YesNo7.- Have you taken prednisone or other steroids in a prolonged period of time, or contraceptives for more than 3 years?YesNo8.- Do you have delayed food allergy/ food hypersensitivity?YesNo9.- Are you bothered by constipation, diarrhea, bloating or abdominal pain?YesNo10.- Do you have unusually dry skin, skin rashes and itchy/ tingling skin?YesNoChildren1.- During the 2 years before your child was born, were you bothered by recurrent vaginitis, menstrual irregularities, premenstrual tension, fatigue, headache, depression, digestive disorders or ‘feeling sick all over’?YesNo2.- Did thrush bother your child?SevereMildNo3.- Did frequent diaper rashes infancy bother your child?Moderate to severeMildNo4.- Did colic & irritability lasting >3 months bother your child during infancy?SevereMildNo5.- Will damp says or damp/moldy places worsen your child’s symptoms?YesNo6.- As recurrent or persistent ‘athlete’s foot’ or chronic fungus infections of your child’s skin or nails bothered him/her?YesNo7.- Has recurrent hives, eczema or other skin problems bothered your child?YesNo8a.- Has your child received: 4 or more courses of antibiotic drug during the past year? Or has he/she received continuous ‘prophylactic’ courses of antibiotic drugs?YesNo8b.- Has your child received: 8 or more courses of ‘board-spectrum’ antibiotics (Such as Amoxicillin, Keflex, Septra, Bactrim or Ceclor) during the past three years?YesNo9.- Has your child experienced recurrent ear problems?YesNo10.- Has your child had tubes inserted in his ears?YesNo11.- Has your child been labeled ‘hyperactive’?SevereMildNo12.- Does learning problems bother your child (despite the normal early development history)?YesNo13.- Does your child have a short attention span?YesNo14.- Is your child persistently irritable, unhappy & hard to please?YesNo15.- Has you kid been bothered by persistent or recurrent digestive problems (constipation, diarrhea, bloating or excessive gas)?SevereModerateMildNo16.- Has your child been bothered by persistent nasal congestion, cough and/ or wheezing?YesNo17.- Is your child unusually tired or unhappy & hard to please?SevereMildNo18.- Has you kid been bothered recurrent headaches, abdominal pain, or muscle aches?SevereMildNo19.- Does your child crave sweets?YesNo20.- Does exposure to perfume, insecticides, gas or other chemicals provoke moderate to severe symptoms in your child?YesNo21.- Does tobacco smoke really bother your child?YesNo22.- Do you feel that your child isn’t well, yet diagnostic tests and studies haven’t revealed the cause?YesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.