Clinic history Si prefieres responder en español da click al boton Español Por favor, activa JavaScript en tu navegador para completar este formulario.Por favor, activa JavaScript en tu navegador para completar este formulario.Name *NombreApellidosAge *Gender *FemaleMalePhone number *Email *Reason for consultation - (Please describe the reason for your consultation in as much detail as possible. Write down the symptoms you are experiencing and the date they began or the total time you have experienced them. Add any details you consider relevant) *Please describe the reason for your consultation in as much detail as possible. Write down the symptoms you are experiencing and the date they began or the total time you have experienced them. Add any details you consider relevant.Current Treatment *Please provide details of any medications or supplements you are currently taking, including name, concentration (e.g. ml or mg) and number of times per day.Non-pathological personal historyDiseñoDo you smoke tobacco? * Yes No Do you drink alcohol? * Yes No Do you exercise? * Yes No How many days per week?1 - 23 a 45 o másPathological personal historyDiseñoChronic diseases *YesNoFor example: diabetes, hypertension, hypothyroidism, obesity, etc.Which?Allergies *YesNoFor Example: Medications, foods, environmental substances, etc.Which?Surgeries *YesNoFor example: appendectomy, hysterectomy, cholecystectomy, etc.Which?Gynecological and Obstetric HistoryDiseñoHow old were you when started menstruating? *Your menstrual cycles are:RegularIrregularDon't have oneDate of last menstruation *Day / Month / YearHow many days does your menstrual cycle last?Less than or equal to 26 days27 to 30 daysMore than 30 daysHave you been pregnant? *YesNoHow many pregnancies in total?How many natural births have you had?How many c-sections have you had?How many abortions have you had?Diseñohave you undergo any hormone replacement treatment? *YesNoWhich?Do you use any contraceptive method? *YesNoWhich?What treatment or therapy are you looking for?DiseñoWhat is the treatment you are looking for at our clinic? *Hormonal balanceGastrointestinal healthAcupuncture (traditional Chinese medicine)Functional medicineIV ozone therapyIV vitamin treatmentOtherHave you received acupuncture treatment before?YesNoHave you received ozone treatment before?YesNoHave you received treatment with intravenous vitamins before?YesNoWhat other therapy are you looking for in our clinic?Hormone Health QuizzesPlease take a few minutes to answer one of our hormone health quizzes. The objective is to guide you as a patient as well as our doctors about possible hormonal alterations that you may present.Thyroid hormonesScore: 10 or less: satisfactory; 11 to 20: possible thyroid hormone deficiency; 21 or more: High possibility of thyroid hormone deficiencyDiseñoI'm sensitive to cold Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy hands and feet are always cold Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyIn the morning, my face is puffy and my eyelids are swollen Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI put on weight easily Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have dry skin Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have trouble getting up in the morning Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI feel more tired at rest than when I am active Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI am constipated Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy joints are stiff in the morning Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI feel like I´m living in slow motion Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyEstrogenScore: 10 or less: satisfactory; 11 to 20: possible thyroid hormone deficiency; 21 or more: High possibility of thyroid hormone deficiencyDiseñoI am losing hair on top of my head Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI'm getting thin, vertical wrinkles above my lips Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy breasts are droopy Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy face is too hairy Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy eyes are dry and easily irritated Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have hot flashes Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI feel tired constantly Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI feel depressed Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy menstrual flow is light Valor seleccionado: 0 0 = moderado / 1-3 = low / 4 = nonWomen with periods: My cycles are irregular, too short (<27 days) or too long (>31 días). Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI dont not feel like making love anymore Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyProgesteroneScore: Postmenopausal women without hormone replacement treatment: 4 or less: Satisfactory, 5 to 8: possible progesterone deficiency, more than 9: Highly probable progesterone deficiency.DiseñoMy breasts are large Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy close friends complain I´m nervous and agitated Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI feel anxious Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI sleep lightly and restlessly Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyProgesteroneScore: Women with menstruation or on hormone replacement treatment: 10 or less: satisfactory, 11 to 20: possible progesterone deficiency, 21 or more: Highly probable progesterone deficiencyDiseñoMy breast are swollen and tender or painful before my period Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy lower belly is swollen Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI'm irritable and aggressive Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI lose my self-control Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have heavy periods Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy periods are continuosly painful Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyTestosteroneScore: 5 or less: Satisfactory, 6 to 10: Possible testosterone deficiency, more than 11: High possibility of testosterone deficiencyTestosteroneScore: 10 or less: Satisfactory, 11 to 20: Possible testosterone deficiency, more than 21: High possibility of testosterone deficiencyDiseñoMy face has gotten slack and more wrinkled Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI've lost muscle tone Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy belly tends to get fat Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI'm constantly tired Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI feel like making love less often than I used to Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy breasts are getting fatty Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI feel less self-confident and more hesitant Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy sexual performance is poorer than it used to be Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have hot flashes and sweats Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI tire easily with physical activity Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyCortisolScore: 10 or less: Satisfactory, 11 to 20: possible cortisol deficiency, 21 or more: Highly probable cortisol deficiencyDiseñoMy face looks thinner Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy friends call me skinny Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have eczema, psoriasis, urticaria (¨nettle ras"), skin allergies, or other rashes Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy heart beats quickly Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyMy blood pressure is low Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI crave salt or sugar (to the extent of bingeing) Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have digestive problems Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI have allergies (hay fever, asthma, etc) Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI'm stressed out Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyI'm easily confused Valor seleccionado: 0 0 = No/ never 1=Not much/ sometimes 2=In moderation/Regularly 3=A lot/Often 4=Tremendously/ConstantlyGastrointestinal Health TestsPlease take a few minutes to answer one of our gastrointestinal health tests. The objective is to guide you as a patient as well as our doctors about possible gastrointestinal disorders that you may present.SIBO TestSIBO stands for Small Intestine Bacterial Overgrowth (this type of bacteria should be in the colon, not the small intestine). Answer the question about symptoms and indicate the severity:Diseño I have bloating/abdominal gas Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have abdominal pain or cramps Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have constipation; when I take fiber, my constipation worsens Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I developed chronic GI/gut symptoms after taking opiates Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have constipation and diarrhea Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have nausea or nausea with belching Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have IBS Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have diverticulitis Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI am lactose intolerance Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have coeliac disease (CD) or gluten sensitivity Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have gluten-sensitivity, avoid gluten and still don’t feel well Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have fat in my stool (steatorrhoea) / floating stool Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have liver cirrhosis Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have chronic fatigue syndrome Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have restless leg syndrome Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have rosacea or acne rosacea Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have breathing issues, problems or difficulties Valor seleccionado: 0 0:Nunca, 1:Rara vez, 2:Algunas veces, 3:A menudo, 4:SiempreI have brain symptoms: brain fog, memory problems Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have chronic B12 deficiency anemia Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have chronic low ferritin with no apparent cause Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have interstitial cystitis Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have hypothyroidism Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysWhen I have taken antibiotics I had dramatic, though transient/brief improvement in my GI/gut symptoms Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI can’t take probiotics, or when I have taken probiotics with prebiotics (FOS, arabinogalactan) my GI/gut symptoms worsened Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI like to eat starches/grains/carbs and include them in most meals and often as snacks (bread, baked goods, pasta, rice, etc.) Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI used to eat starches/grains/carbs and don’t eat them anymore Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI was not breast fed as a baby Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysAs a child, eating at the dinner table was not a pleasant time or we did not eat at the table (grab & go, eat alone, in front of TV, etc.) Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have taken antibiotics often or regularly as an adult Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have experienced periods of severe stress or shock Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have bloating/burping after meals Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have constipation (push/strain, hard, dry stool, pellets) Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have alternating constipation and diarrhea Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have diarrhea Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have heartburn/reflux/GERD Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have leaky gut or intestinal permeability Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have IBD (Crohn’s or ulcerative colitis) Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have food sensitivities Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have a dairy sensitivity and/or trouble with dairy Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have CD and am on a gluten free diet and I still don’t feel well Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always On a CT scan, they couldn’t see my pancreas due to a gas bubble Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have NASH (non-alcoholic steatohepatitis) or fatty liver Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have fibromyalgia Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have joint pain Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = always I have skin issues: eczema, atopic dermatitis, psoriasis Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have scleroderma or lupus Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have headaches Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have autism Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have chronic iron deficiency anemia Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have a chronic vitamin D deficiency Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have diabetes type I or type II Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysWhen I take fiber, my GI/gut symptoms worsens Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI had food poisoning or “traveller’s diarrhoea” and I’ve never felt the same since Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI tend to graze/nibble throughout the day rather than eat 3 square meals Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI currently eat or have a history of eating lots of grains/carbs/starches and feel I don’t do well when I eat them Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI was delivered by cesarean (C-section) Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysMy mother (& perhaps grandmother) had same digestive problems as me Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI was given antibiotics regularly as a child (ear infection, tonsillitis, strep throat, etc) Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have taken oral birth control pills regularly as an adult Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysI have taken morphine or opiates Valor seleccionado: 0 0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = alwaysLeaky gut TestLeaky gut or leaky gut syndrome is a digestive condition that affects the lining of the intestines. This causes voids in the intestinal walls to allow bacteria and other toxins to pass into the bloodstream. Score: 0 - 5: unlikely to have Leaky gut; 6 - 12: you may have leaky gut; 13 or more: highly likely that you have leaky gut.DiseñoDo you struggle with losing weight?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you have difficulty or pain with bowel movements?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you experience lower abdominal pain when passing gas or stools?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you experience occasional diarrhea?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you feel constipated often?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsIs your stool typically hard in texture?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you experience a coated or fuzzy feeling on your tongue?yesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you have the urge to pass gas shortly after you eat?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you need laxatives or a stool softener to help with bowel movements?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you feel bloated or have indigestion after eating?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you struggle with bad breath?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you experience stomach pain after eating?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you frequently experience heartburn?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDoes eating salads and other high fiber foods make you more constipated?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsHave you felt tenderness or pain on the left side under your rib cage?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you feel nauseated or experience vomiting?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you feel a constant urge to urinate?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsAre you experiencing hunger and thirst often?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you often experience fatigue or low energy levels?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you have unexplained skin issues or rashes?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsHave you noticed changes in your mood or mental well-being?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsAre you prone to frequent headaches or migraines?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsDo you often feel mentally foggy or have difficulty concentrating?YesSometimesNoYes=3 points, Sometimes=1 point, No=0 pointsCandida Scaning TestCandida is a type of yeast that in small amounts is harmless inside and outside the body. However, certain factors can cause excessive growth of this yeast and cause a series of signs and symptoms. Score of the candida scanning test for women60 or less: Yeast is less likely to cause health problems; 61-121: There may be health problems related to yeast; 122-180: Health problems related to yeast are likely; 181 or higher: Health problems related to yeast are almost certainScore of the candida scanning test for men40 or less: Yeast is less likely to cause health problems; 41-90: Health problems related to yeast are possible; 91-140: Health problems related to yeast are likely; 141 or higher: Health problems related to yeast are almost certain DiseñoHave you taken tetracyclines (Sumycin®, Panmycin®, Vibramycin®, Minocin®, etc.) or other antibiotics for acne for one month or longer?Yes (35)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Have you, at any time in your life, taken other “broad-spectrum” antibiotics for respiratory, urinary, or other infections (for two months or longer, or in shorter courses four or more times in one year)*?Yes (35)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Have you taken a broad-spectrum antibiotic drug, even a single course?Yes (6)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Have you, at any time in your life, been bothered by persistent prostatitis, vaginitis, or other problems affecting your reproductive organs?Yes (25)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Have you been pregnant?One time? (3)Two or more times? (5)For each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Have you taken birth control pills?For six months to two years? (8)For more than two years? (15)For each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Have you taken prednisone, decadron, or other cortisone-like drugs? For two weeks or less? (6)For more than two weeks? (15)For each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Does exposure to perfumes, insecticides, fabric shop odors, and other chemicals provoke symptoms? Mild symptoms? (5)Moderate to severe symptoms? (20)For each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Are your symptoms worse on damp, muggy days or in moldy places?Yes (20)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Have you had athlete’s foot, ringworm, “jock itch,” or other chronic fungus infections of the skin or nails? Mild to moderate? (10)Severe or persistent? (20)For each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Do you crave sugar?Yes (10)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Do you crave alcoholic beverages?Yes (10)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Do you crave breads?Yes (10)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Does tobacco smoke really bother you?Yes (10)NoFor each “yes” answer, check the box next to that question. Add up the total score and record it at the end of this section.Aviso de Privacidad *I accept the terms and conditions regarding the submission of personal data.By submitting your personal data, you agree to our Privacy Notice. To learn how we protect and use your information, please review the full notice at https://santulangarden.com/privacy-policy/Send
