Celiac Disease and Gluten Sensitivity: Diagnosis and Management

Answers marked with a * are required.

The National Foundation for Celiac Awareness (NFCA) has a dual approach in our work with celiac disease: To gain a diagnosis for those who suffer with celiac disease and gluten sensitivity, and to improve the quality of life for those who have been diagnosed.

This survey is geared to help NFCA and our partners meet both aspects of this mission. We want to…

• Learn more about the diagnostic process as actually experienced by you, the people who have determined that you have celiac disease. This includes those of you who have been self-diagnosed.

• Identify the health problems and complications that persist for individuals after their diagnosis and adoption of a gluten-free diet.

• Determine other, possibly related, healthcare issues for those who have been diagnosed with celiac or gluten sensitivity.

Through this survey, we hope to better address your needs, as well as those of the millions suffering with celiac and gluten sensitivity. Specifically, we plan to include this information in NFCA’s programs for medical professionals.

For this survey, NFCA is working with Drs. Vikki and Richard Petersen of the HealthNOW Medical Center, experts in gluten sensitivity.

We thank you for your time and interest!

1. Have you been diagnosed with celiac disease?

Yes
No

2. When (What year, approximately)?

3. How were you diagnosed?

By biopsy
By blood test
Genetic test
Self-diagnosed

4. Have you been diagnosed with gluten sensitivity?

Yes
No

5. When? (What year approximately)

6. How were you diagnosed?

By lab test
Stool test
Self-diagnosed

7. Do you suffer from any other autoimmune diseases?

Yes
No

8. If yes, which diseases?

Type 1 Diabetes
Thyroid disease (Hashimoto’s)
Rheumatoid Arthritis
Multiple Sclerosis
Crohn’s Disease
Ulcerative Colitis
Lupus
Sjogren’s Syndrome
Cirrhosis (primary biliary)
Vasculitis
Other (Please Specify)

9. Do any family members have an autoimmune disease?

Yes
No

10. Have those family members been tested for celiac disease or gluten sensitivity?

Yes
No

11. Are you having difficulty maintaining a gluten-free diet?

I’m very diligent about my diet and am 100% gluten-free.
I try but sometimes I get some gluten.
I “cheat” sometimes but not often.
I am unable to follow the gluten-free diet.

12. Have you had a follow-up medical review since your diagnosis?

Yes
No

13. If yes, did it include one the following tests?

Dexascan (bone density test)
Vitamin deficiencies
Annual antibody check

14. Do you presently suffer from any digestive complaints?

Yes
No

15. If yes, please indicate which:

Gas
Bloating
Diarrhea
Constipation
Acid Reflux
Other (Please Specify)

16. Do you react negatively to dairy products (lactose, casein)?

Yes
No

17. Do you react negatively to other foods?

Yes
No

18. If yes, please indicate which:

Soy
Corn
Shellfish
Peanuts
Tree nuts
Eggs
Other (Please Specify)

19. How would you rate your overall health?

Excellent
Good
Fair
Poor

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