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SECTION A: HISTORY
8. Does exposure to perfumes, insecticides,fabric shop odors and other chemicals provoke.
For each “yes” answer in Section A, circle
Optimum Function:
the point score for that question. Total
Dysbiosis Questionnaire
your score and record it in the box at theend of the section. Then move to sections 9. Are your symptoms worse on damp, muggy This questionnaire is designed for adults and the scoring system is not asappropriate for children. It lists factors in 1. Have you taken tetracyclines (Sumycin, 10. Have you had athlete’s foot, ring worm, Panmycin, Vibramycin, etc.) or other antibiotics “jock itch” or other chronic fungous infections for skin acne or anything else for at least one healthy gastrointestinal bacteria, directly Have such infections been……………………… or indirectly promoting the overgrowth of 2. Have you at any time in your life, taken
other antibiotics for respiratory, urinary or other found in individuals with dysbiosis related infections in shorter courses four or more times Filling out and scoring this questionnaire 3. Have you taken an antibiotic drug – even a evaluate the possible role of dysbiosis incontributing to your health problems. Yet 4.Have you, at any time in your life, been will not provide and automatic “Yes” or 14. Does tobacco smoke really bother you?.10 bothered by recurrent or persistent prostatitis, vaginitis or other problems affecting your 15. Have you ever had a parasitic infection, Note: Dysbiosis refers to the condition
dysentery, or unexplained episode of prolonged where the normal healthy population of
5. Have you taken birth control pills…………… beneficial bacteria in the intestines has been
16. Have you ever consumed chlorinated (tap) disrupted, leaving it open to the overgrowth
drinking water for more than 3 months?.15 of yeast, fungi, parasites and potentially
harmful strains of bacteria. This intestinal
imbalance in turn adversely affects other
6. Have you been pregnant………………….
important systems via toxic stress and
interfering with nutrient absorption and
utilization.
7. Have you taken prednisone, Decadron orother cortisone type drugs………………….
19. Do you drink alcohol or coffee daily?.20 For more than 6 months?.25For more than 2 weeks?.15 20. Do you have or have you ever had an ulcer, colitis, crohn’s disease or diverticulitis?……….35 Total Score, Section A:
SECTION B: MAJOR SYMPTOMS
SECTION C: OTHER SYMPTOMS
appropriate figure on the line following the appropriate figure on the line following that Total Score Section C:
If the symptom is occasional or mild = 1pt Total Score Section A:
If the symptom is frequent &/or moderately If a symptom is frequent &/or moderate = Total Score Section B:
If the symptom is sever &/or disabling = Grand Total Score
Add total score and record it in the box at over 120 and in men with scores over 80.
15. Persistent vaginal burning or itching ______ and 40 in men, dysbiosis is unlikely to be contributing to your health challenges.
20. Cramps and /or other menstrual irregularities 26. Wheezing or shortness of breath _____ Dr. Tim Irving DC, LMT, Nutritionist, CKTP Total Score, Section B

Source: http://optfunction.com/source/content/dysbiosis_questionnaire.pdf