History

1. Have you taken a broad spectrum antibiotic, even a single course?
   Yes
   No

2. Have you taken tetracyclines (or other antibiotics for acne) for one month or longer?
   Yes
   No

3. 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 for 4 or more times) in a 1-year period?
   Yes
   No

4. Have you at any time in your life been troubled by persistent prostatitis, vaginal problems or had 3 or more episodes of vaginitis in a year?
   Yes
   No

5. Have you taken prednisone, Decadron®, or other cortisone-type drugs for...
   more than two weeks
   two weeks or less
   not at all

6.Have you been pregnant...
   two or more times
   one time
   never

7.Have you taken birth control pills for...
   more than 2 years
   6 months - 2 years
   less than 6 months or never

8. Does exposure to perfume, insecticides, fabric shop odors and other chemicals provoke...
   moderate to severe symptoms
   mild symptoms
   no symptoms

9. Are your symptoms worse on damp, muggy days or in moldy places?
   Yes
   No

10. Have you had athlete's foot, ring worm, "jock itch," or other chronic fungus infections of the skin or nails, and if so, have such infections been...
   severe or persistent
   mild to moderate
   have never had such infections

11. Do you crave alcoholic beverages?
   Yes
   No

12. Do you crave sugar?
   Yes
   No

13. Do you crave breads?
   Yes
   No

14. Does tobacco smoke REALLY bother you?
   Yes
   No

Major Symptoms

Other Symptoms