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Diagnostic questionnaire
We need an idea of how long you have been infected & how severe the infection may be. This will help us to give you the best advice on how to eliminate your Candida infection.

Name and surname
Date
Postcode
Age
Male/Female
Email address
confirm email address
Are you already taking threelac? Yes No


Grade the following symptoms on a scale of 1-10
0 = never, 2 or 3 = sometimes
5 or 6 = often, 8 or 9 = always
10 = severe/debilitating

** Tip for faster typing: Use the TAB key to move to the next entry box
 
Now (before start of Threelac)
No of years with each sympton
Skin rashes / itchy skin
Numbness/burning/tingling
Itchy eyes
Eczema
Athletes foot
Cold hands / feet
Bloating / abdominal pain
Indigestion/ acidity/ heartburn
Food intolerance (milk/wheat)
Trapped wind
Constant Thirst
Mucus in stools
Rectal itching
Irritable bowel syndrome (IBS)
Diarrhoea
Constipation
Hypoglycemia ( low sugar levels)
Sugar cravings
Shaking /Irritable when hungry
Heart palpitations
Headaches
Migraines
Ear infections
Sinus problems
Recurrent back / neck / shoulder aches
Constant phlegm / nasal congestion
sensitivity to chemical smells / perfumes
Blurred vision
Spots in front of eyes
Dizziness
Nausea
Disorientated
Inability to concentrate
loss of libido (sex & Life)
Frequent visits to toilet at night
Unrefreshed sleep
Night sweats
Anxiety
Brain Fog
Panic attacks
Mild depression
Sleepiness
Mood swings
Tiredness / fatigue
Muscle weakness
Joint pain / inflammation
Recurrent urinary infections
Cystitis (pain urinating)
Thrush ( oral )
Thrush ( intimate)
Prostatitis
Frequent colds / flu
General feeling “run down”
Hypothyroidism (low Thyroid function)
Women only:    
Do you suffer painful/ heavy periods ?
Cramps/ menstrual irregularities
The origin of the infection    
Have you taken prolonged courses of Steroids , Antibiotics:
in the past year:

 

  
None
1x
2x
3x
in the past 5 years:    
3x
4x
5x
6x
7x
8x
As a teenager were you given long term antibiotics for acne, or other bacterial infections ? Yes No
Did you suffer from attention deficit disorder as a child ? Yes No
Supplements:
Exact name of supplement
What daily dose?
Are you taking Magnesium Supplements ?
Are you taking Calcium supplements ?
Are you taking Zinc supplements ?
Are you taking Vit B 12 (sub-lingual)?
Do you have any other details that would help me to identify other issues?
Press the submit to send your analysis. We will reply with feedback about particular areas.
   
Please discuss all your medical conditions with a qualified Medical practioner. This should not substitute any dialogue with your GP regarding your medical condition.
     
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