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1.
Have you been diagnosed with celiac disease?
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2.
When (What year, approximately)?
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3.
How were you diagnosed?
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4.
Have you been diagnosed with gluten sensitivity?
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5.
When? (What year approximately)
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6.
How were you diagnosed?
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7.
Do you suffer from any other autoimmune diseases?
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8.
If yes, which diseases?
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9.
Do any family members have an autoimmune disease?
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10.
Have those family members been tested for celiac disease or gluten sensitivity?
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11.
Are you having difficulty maintaining a gluten-free diet?
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12.
Have you had a follow-up medical review since your diagnosis?
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13.
If yes, did it include one the following tests?
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14.
Do you presently suffer from any digestive complaints?
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15.
If yes, please indicate which:
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16.
Do you react negatively to dairy products (lactose, casein)?
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17.
Do you react negatively to other foods?
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18.
If yes, please indicate which:
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19.
How would you rate your overall health?
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20.
Thank you very much for completing this survey!
If you wish to receive additional information concerning the results of this survey, celiac disease or the gluten-free diet, please provide contact information, including the following items, in the text box provided below:
□ First Name
□ Last Name
□ Email
□ Street Address
□ City, State, Zip
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