It all started when…


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 ___


    ___ 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 ___


    ___ 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 ____


    ___ Frequent or urgent urination

    ___ Difficulty urinating

    ___ Penile itching or discharge

    ___ Vaginal itching or discharge

    Total ___


    ___ 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 ___


    ___ 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 ____


    ___ Mood Swings

    ___ Anxiety, fear, nervousness

    ___ Anger, irritability, aggressiveness

    ___ Depression

    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.


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