28-DAY CLEANSE GUT C.A.R.E. by Dr. Vincent Pedre. Pre-Program Medical Symptoms Questionnaire

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1 28-DAY CLEANSE HAPPY GUT GUT C.A.R.E. by Dr. Vincent Pedre Pre-Program Medical Symptoms Questionnaire NAME ADDRESS PHONE RATE EACH OF THE FOLLOWING SYMPTOMS BASED UPON HOW YOU HAVE FELT OVER THE PAST 3090 DAYS: POINT SCALE Never or almost never have the symptom Occasionally have it, symptom is not severe Occasionally have it, symptom is severe Frequently have it, symptom is not severe Frequently have it, symptom is severe HEAD Headaches Faintness Dizziness Insomnia

2 EYES Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (does not include near or far-sightedness) EARS Itchy ears Earaches, ear infections Drainage from ear Ringing in ears NOSE Stuffy nose Sinus problems Hay Fever Sneezing attacks Excessive mucus formation

3 MOUTH / THROAT Chronic coughing Frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums, lips White coating on tongue Canker sores SKIN Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating HEART Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain

4 LUNGS Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing DIGESTIVE TRACT Nausea, vomiting Diarrhea Constipation Bloated feeling Excessive belching, passing gas Heartburn Intestinal / stomach pain JOINTS / MUSCLE Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness

5 WEIGHT Binge eating / drinking Craving certain foods Excessive weight gain Compulsive eating Water retention Underweight ENERGY / ACTIVITY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness MIND Poor memory Confusion, poor comprehension Mental fog Poor concentration Poor physical coordination Difficulty in making decisions Word-finding difficulties Learning disabilities

6 EMOTIONS Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression OTHER Frequent illness Frequent or urgent urination Genital itch or discharge Medications GRAND NOTE Each individual score can help you compare in which part of your body or which systems you have the most problems. The total score is meant to be used as a baseline for comparison with your score at the end of the program. Each of these scores can help you see where the most change happened, what areas you still need to work on, and how much you improved between the beginning and end of the GUT C.A.R.E. Program.

7 KEY TO QUESTIONNAIRE Finished! Drum roll please, and now for your score. First, add up your individual scores and total each group. Next, add each group score to get your grand total. OUR HAPPY GUT RECOMMENDATIONS BASED ON YOUR SYMPTOM SEVERITY OPTIMAL < 15 MILD MOD SEVERE > 150 Welcome! You already have a Happy Gut! You re a health superstar. Your gut is talking. It is gurgling and asking you for a diet makeover. Follow the Happy Gut Diet for a new you in just 28-days. You ve got mail. From your gut. And it s recommending the Happy Gut Cleanse + the 28-Day GUT C.A.R.E. Program. Your body really needs a gut reboot! How soon can you start the Happy Gut Cleanse? NOTE Anyone with mild, moderate, or severe symptoms can add the Happy Gut Cleanse Kit to complement the Happy Gut Program. We ve seen remarkable results with patients in just 28 days. If you have been feeling unwell for way too long and now want a fresh start, and will settle for nothing less than the best total gut and health reboot... here s to your HAPPY GUT Cleanse!

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