Questionnaire

In an effort to aid in medical research, answer the questions as accurately as possible. If you are providing information for someone other than yourself, please indicate the relationship. if you are providing information for multiple individuals, use separate questionnaires for each individual.

1. Pertains to:

Self
Spouse
Child
Other

2. This person is:

Male
Female

3. Year born?

4. Did this individual have colic as an infant?

Yes
No

5. Does this individual have celiac disease or gluten intolerance?

Yes
No

6. Has this individual ever been tested for celiac disease?

Yes
No

If yes, which test was administered? (check only one, as the highest degree of testing)

Celiac Blood Panel: antibody test
Celiac Blood Panel: genetic test
Endoscopy