Celiac Disease and Gluten Sensitivity: Diagnosis and Management
Answers marked with a * are required.
1. Have you been diagnosed with celiac disease?


2. When (What year, approximately)?
3. How were you diagnosed?

4. Have you been diagnosed with gluten sensitivity? 


5. When? (What year approximately)
6. How were you diagnosed?

7. Do you suffer from any other autoimmune diseases?


8. If yes, which diseases?

9. Do any family members have an autoimmune disease?


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


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


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


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

14. Do you presently suffer from any digestive complaints?


15. If yes, please indicate which:

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


17. Do you react negatively to other foods?


18. If yes, please indicate which:


19. How would you rate your overall health?



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:

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