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:




2. This person is:


3. Year born?
4. Did this individual have colic as an infant?
 

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

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

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