This questionnaire lists symptoms commonly found in individuals with hypothyroidism or low thyroid function.

The grand total will help determine if your symptoms may be connected to low thyroid function. This questionnaire serves as a helpful tool for you and your physician but does not provide a definite ‘yes’ or ‘no’ answer. A full examination including a comprehensive medical history, physical examination and laboratory tests are all important to properly determine the cause of your symptoms.

Print this test, or record your answers on a separate piece of paper.

For each symptom that is present, record a score of 6 points.

________ FATIGUE

________ COLD INTOLERANCE

________ DIFFICULTY LOSING WEIGHT

________ DRY SKIN

________ GOITER (swelling of thyroid gland)

________ LOW TEMPERATURE

________ ELEVATED CHOLESTEROL

________ TOTAL SCORE, SECTION A

For each symptom that is present, record a score of 4 points.

________ WEAKNESS

________ CONSTIPATION

________ HEAVY MENSTRUAL PERIODS

________ PUFFY FACE AND EYELIDS

________ DRY OR THINNING HAIR, THINNING OF LATERAL EYEBROWS

________ SWOLLEN ANKLES

________ LOW BLOOD PRESSURE

________ TOTAL SCORE, SECTION B

For each symptom that is present, record a score of 2 points.

________ DEPRESSION

________ SLOW HEARTBEAT

________ THIN, BRITTLE NAILS

________ MUSCLE CRAMPS

________ SNORING

________ THICKENING OF FACIAL FEATURES

________ ANEMIA (low red blood cell count)

________ FAMILY HISTORY OF THYROID PROBLEMS

________ TOTAL SCORE, SECTION C

For each symptom that is present, record a score of 1 point.

________ FORGETFULNESS

________ HEADACHES

________ HOARSENESS / CHANGE IN VOICE

________ PALE COMPLEXION

________ SLOW SPEECH

________ ABSENCE OF SWEATING

________ DECREASED SENSE OF TASTE AND SMELL

________ SHORTNESS OF BREATH

________ THICK TONGUE

________ LOSS OF APPETITE

________ HIGH BLOOD PRESSURE

________ TOTAL SCORE, SECTION D

________ TOTAL SCORE, SECTION C

________ TOTAL SCORE, SECTION B

________ TOTAL SCORE, SECTION A

________ GRAND TOTAL OF A,B,C,D

The grand total will help determine if your symptoms may be connected to low thyroid function. This questionnaire serves as a helpful tool for you and your physician but does not provide a definite ‘yes’ or ‘no’ answer. A full examination including a comprehensive medical history, physical examination and laboratory tests are all important to properly determine the cause of your symptoms.

Low thyroid function is very likely present with a grand total score over 40.

Low thyroid function is probably present with a grand total score over 30.

Low thyroid function is possibly present with a grand total score over 20.

Low thyroid function is unlikely to be present with a grand total score below 20.

Celebration of Health Association

Risk of Yeast Score

This questionnaire asks for factors which promote the growth of yeast.

Filling out and scoring this questionnaire should help you and your physician evaluate the role Candida albicans may be contributing to your health problems. Yet, it will not provide an automatic “yes” or “no” answer.  A comprehensive history and physical examination are important.  In addition, laboratory studies, X-rays and other types of tests may also be appropriate. 

 The use of nasal or bronchial sprays containing cortisone and/or other steroids, promote yeast overgrowth in the respiratory tract.

For each “YES” answer circle the Point Score.	SCORE
1.   Have you taken antibiotics for acne for 1 month or longer?	40
2.   Have you taken other “broad spectrum” antibiotics for any infections repeatedly or for more than one month?	20
3.   Have you taken a broad spectrum antibiotic drug at least once?	10
4.   Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs?	25
5.   Have you been pregnant 2 or more times?       Only once?	5
	3
6.   Have you taken birth control pills or used the patch for at least 6 months?	15
7.   Have you taken prednisone or other steroid medication in any form for more than 5 days?	15
8.   Does exposure to fumes, odors, and chemicals cause moderate to severe symptoms?       Mild symptoms?	20
	5
9.   Are your symptoms worse on damp, muggy days or in moldy places?	25
10. Have you had athlete’s foot, ringworm, “jock itch” thrush or other fungus infections of the skin or nails?	20
11. Do you crave sugar?	10
12. Do you crave breads?	10
13. Do you crave alcohol?	10
14. Does tobacco smoke bother you?	10

TOTAL___________

For each symptom which is present, enter the appropriate figure in the Point Score column: 

If a symptom is mild…………………………………………………………3 points

If a symptom is frequent and/or moderately severe…….. 6 points

If a symptom is severe……………………………………………………..9 points

	Score		Score
1.  Fatigue		4. Diarrhea
2.  No ambition		5.  Gas or bloating
3.  Poor memory		6.  Vaginal discharge with/without burning itching
7.  Brain fog		16. Prostate infection
8.  Inability to make decisions		17. Impotence
9.  Numbness, burning or tingling		18. Decreased sex drive
10.  Insomnia		19. Endometriosis
11.  Muscle aches		20. Irregular menstrual bleeding or cramps
12.  Leg cramps		21. Premenstrual tension (PMS)
13. Pain in joints		22. Panic attacks, anxiety or crying
14. Abdominal pain		23. Cold hands or feet
15. Constipation		24. Shaking or irritable when hungry
Score two points each if you have these symptoms
1. Drowsy		16. Dry mouth or throat
2. Jittery		17. Rash or blisters in mouth
3. Uncoordinated		18. Bad breath
4. Cannot concentrate		19. Noticeable body odor
5. Mood swings		20. Nasal congestion or postnasal drip
6. Headaches		21. Laryngitis or sore throat
7.  Balance problems		22. Persistent cough
8. Fullness of or above ears		23. Tightness in chest
9. Bruise easily		24.  Wheezing or shortness of breath
10. Persistent rashes or itching		25. Urinary frequency or urgency, burning on urination
11. Psoriasis or hives		26. Floaters in eyes or trouble focusing
12. Indigestion or heartburn		27.  Burning, tearing, or itching of eyes or nose
13. Food allergies		28.  Recurrent infections or fluid in ears
14. Mucus in stools		29.  Ear pain or itching
15. Rectal itching
TOTAL		TOTAL

GRAND TOTAL SCORE _________

A high grand total score indicates that your health problems are connected to yeast and mold.

Yeast-connected health problems are almost certainly present in women with scores over 175 and in men with scores over 125.

Yeast-connected health problems are probably present in women with scores over 110 and in men with scores over 75.

Your doctor should evaluate you for yeast if your score is over 50 or if you have specific yeast-related symptoms.

The information on this website is only the opinion of COHA.  It is not meant to be medical advice.  Before you do anything, you should seek the advice of your personal physician.  This is information only.  No treatment is proposed, no cure is implied, and no claim is made for the effectiveness of any treatment or test.