HEALTH QUESTIONNAIRE

Review the questions below or print this page and note your answers!

Section 1: Symptoms

Check each of the symptoms that you have experienced at least once a week during the past three months:

_____Bloating

_____Gas and or stomach cramping

_____Diarrhea or runny stools

_____Constipation

_____Joint pain

_____Numbness or tingling in you extremities

_____Itchy skin lesions

_____Constant unexplained fatigue

_____Frequent headaches or migraines

Section 2: Diagnoses

Check if you have had or been diagnosed with any of the following:

_____Irritable bowel syndrome

_____Eczema or unexplained contact dermatitis

_____Fibromyalgia

_____Chronic fatigue syndrome

_____Nervous stomach (non-ulcer dyspepsia)

Section 3: Associated Illnesses

Check if you have any of the following:

_____Lactose intolerance

_____Osteopenia and/or osteoporosis

_____Autoimmune disorders

         ___Thyroid disease (hypo/hyper)

         ___Diabetes mellitus, type 1

         ___Sjogren’s syndrome

         ___Chronic liver disease

_____An immediate family member with an autoimmune condition

_____Peripheral neuropathy

_____Non-Hodgkin’s lymphoma

_____Small intestinal cancer

_____Psychiatric disorders or depression

_____Anemia (iron deficiency)

_____Infertility

Scoring

If you have checked one or more in either Section 1 or 2 and have any of the illnesses in Section 3 (especially males or women under forty-five with osteopenia and/or osteoporosis), you should consider testing for celiac disease.

If you have checks in all three sections, you and your doctor should definitely explore a diagnosis of celiac disease.

All of the symptoms in Section 1, all of the diagnoses in Section 2, and all of the associated illness in Section 3 are intimately related to celiac disease. One in every 100 people is affected by celiac disease; and 97 percent of them are undiagnosed!