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!