Happy Gut

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It all started when…

BEFORE AND AFTER QUESTIONNAIRE

Sometimes you forget the details of how bad you felt in the beginning. Often, I have to remind my patients of the symptoms they reported at our first meeting. Recording your symptoms at this point will provide a reference and reminder of how your current way of living and eating is affecting your health. The Happy Gut Pre-Program Symptoms Questionnaire will help you rate your symptom score now as a basis of comparison. Base your answers on how you have generally felt over the thirty to ninety days prior to starting the new program. This will be your pre-program symptom score. It is a great way to track your progress when you complete the Happy Gut Diet and our nutrition program, and also a record of how you felt while it is fresh in your mind.

HAPPY GUT PRE-PROGRAM SYMPTOMS QUESTIONNAIRE Rate each of the following symptoms based upon how you have felt over the past thirty to ninety days: POINT SCALE 0 Never or almost never have the symptom 1 Occasionally have it, symptom is not severe 3 Occasionally have it, symptom is severe 5 Frequently have it, symptom is not severe 7 Frequently have it, symptom is severe 

 
  1. HEAD

    ___ Headaches/migraines

    ___ Light-headedness

    ___ Dizziness

    ___ Insomnia

    Total ___

  2. EYES

    ___ Watery, red, or itchy eyes

    ___ Swollen or sticky eyelids

    ___ Bags or dark circles under eyes

    ___ Blurred or tunnel vision (does not include near- or far-sightedness)

    Total ___

  3. EARS

    ___ Itchy ears

    ___ Ear infections, earaches

    ___ Drainage from ear

    ___ Ringing in ears

    Total ___

  4. NOSE

    ___ Nasal congestion

    ___ Sinus problems

    ___ Runny nose

    ___ Sneezing attacks

    ___ Excessive mucus production

    ___ Frequent Colds

    Total ___

  5. MOUTH/THROAT

    ___ Chronic cough

    ___ Frequently clearing throat of mucus

    ___ Sore throat, hoarseness, loss of voice

    ___ Swollen, pale, and/or red tongue or gums

    ___ White, frothy coating on tongue

    ___ Canker sores or mouth ulcers

    Total ___

  6. GUT

    ___ Nausea, vomiting

    ___ Diarrhea

    ___ Constipation

    ___ Bloated Feeling

    ___ Excessive belching, passing gas

    ___ Heartburn

    ___ Abdominal pain

    Total ___

  7. SKIN

    ___ Acne

    ___ Hives, rashes, eczema

    ___ Hair loss or thinning hair

    ___ Flushing, hot flashes

    ___ Excessive sweating

    Total ___

  8. CHEST/HEART

    ___ Irregular or skipped heartbeat

    ___ Rapid or pounding heartbeat after eating

    ___ Excessive sweating

    Total ___

  9. LUNGS

    ___ Chest tightness or congestion

    ___ Asthma, wheezing or bronchitis

    ___ Shortness of breath

    ___ Difficulty breathing with exertion

    Total ____

  10. GENITAL/URINARY

    ___ Frequent or urgent urination

    ___ Difficulty urinating

    ___ Penile itching or discharge

    ___ Vaginal itching or discharge

    Total ___

  11. JOINTS/MUSCLES

    ___ Painful, swollen, or achy joints

    ___ Arthritis

    ___ Stiffness or limitation of movement

    ___ Painful or achy muscles

    ___ Feeling of weakness or fatigue

    Total ___

  12. WEIGHT

    ___ Excessive eating/drinking

    ___Craving certain foods (like bread or desserts)

    ___ Excessive weight gain

    ___ Compulsive eating

    ___ Water retention

    ___ Unexpected weight loss

    Total ___

  13. ENERGY/ACTIVITY

    ___ Fatigue, sluggishness

    ___ Lethargy, lack of motivation to move

    ___ Excessive energy

    ___ Agitation

    Total ___

  14. MIND

    ___ Memory Loss

    ___ Confusion, poor comprehension

    ___ Mental fog

    ___ Poor concentration

    ___ Poor balance

    ___ Indecisiveness

    ___ Word-finding difficulties

    ___ Difficulty learning

    Total ____

  15. EMOTIONS

    ___ Mood Swings

    ___ Anxiety, fear, nervousness

    ___ Anger, irritability, aggressiveness

    ___ Depression

    Total ___

    GRAND TOTAL ___

Each individual score can help you determine your trouble spots. The total score is a baseline for comparison with your score at the end of the program. At the end of the program you will fill out the same questionnaire.

Reference

Pedre, V. (2015) Happy Gut: The Cleansing Program to Help You Lose Weight, Gain Energy, and Eliminate Pain. New York, NY: HarperCollins Publishers