| Name: _______________________________ Date of Birth:_______________________ |
|
Sex:  Female
Male |
|
| Race: Caucasian African-American Asian Hispanic Other ___________ |
|
| I AM a: |
|
| First-degree relative of a celiac patient (please
check below): |
|
Child Parent
Sibling
|
|
| Second-Degree relative of a celiac
patient (please check below): |
|
Grandchild Grandparent
Aunt Uncle
Cousin - of a celiac patient
|
|
| The Celiac disease of my relative was confirmed by intestinal biopsy:
Yes
No |
| ------------------------------------------------------------------------- |
| I do not have celiac disease
and I do not have a
relative with celiac disease |
| ------------------------------------------------------------------------- |
| I AM a patient with celiac disease.
Is your diease biopsy proven? Yes No |
| ------------------------------------------------------------------------- |
| I have a disease, which can be associated with celiac disease (please check below): |
|
| Diabetes Osteoporisis
Lactose-intolerance Irritable bowel
syndrome |
| Thyroid problem Chronic diarrhea
Iron-deficiancy anemia
Short stature |
| Children with growth failure Reccurent abdominal pain Other disease
_________ |
| _______________________________________________________________________________ |
| If you are a relative, do you live with your celiac relative? Yes No |
|
| Telephone: ______________________________ Fax: ___________________________________ |
| Email ___________________________________________________________________________ |
| Address: ___________________________________________ Country _____________________ |
| City:_______________________________ State
_____________ Zip ___________________ |
|
| I request to send my serology test report to my primary
care physician. Her/His name and address is: |
| _____________________________________________________________________ |
| _____________________________________________________________________ |
| _____________________________________________________________________ |
| YOUR DISEASES IN THE PAST AND NOW (if
YES, please specify): |
|
| Disease |
Yes |
No |
|
|
|
|
|
| Ear/Throat |
|
|
______________________________________ |
| Eye |
|
|
______________________________________ |
| Lung |
|
|
______________________________________ |
| Heart |
|
|
______________________________________ |
| Kidney |
|
|
______________________________________ |
| Neurological/Psychiatric |
|
|
______________________________________ |
| Gastrointestinal |
|
|
______________________________________ |
| Liver |
|
|
______________________________________ |
| Skin/Muscle/Joint |
|
|
______________________________________ |
| Endocrine (diabetes, thyroid) |
|
|
______________________________________ |
| Surgeries |
|
|
______________________________________ |
| Other |
|
|
______________________________________ |
|
|
| DO YOU HAVE ALLERGIES? (if YES, please
specify): |
|
| Allergy |
Yes |
No |
|
|
|
|
|
| Food Allergy |
|
|
______________________________________ |
| Asthma |
|
|
______________________________________ |
| Other (pollen, drug, etc.) |
|
|
______________________________________ |
|
|
| DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS? (if
YES, please specify): |
|
| Symptom |
Yes |
No |
|
|
|
|
|
| Diarrhea/loose stools, Constipation |
|
|
______________________________________ |
| Gaseousness Abdominal pain |
|
|
______________________________________ |
| Heartburn (> more than once per month) |
|
|
______________________________________ |
| Joint pain |
|
|
______________________________________ |
| Weakness, fatigue |
|
|
______________________________________ |
| Weight loss |
|
|
______________________________________ |
| Other |
|
|
______________________________________ |
|
|
| ARE YOU ON A SPECIAL DIET? (if YES, specify
from-to) |
|
| Type of diet |
Yes |
No |
|
|
|
|
|
| Gluten-free |
|
|
______________________________________ |
| Milk-free |
|
|
______________________________________ |
| Milk-sugar-free |
|
|
______________________________________ |
| Other diet |
|
|
______________________________________ |
|
|
| DISEASES IN YOUR FAMILY (if YES, please
specify the family member who has the disease) |
|
| Disease |
Yes |
No |
|
|
|
|
|
| Celiac disease |
|
|
______________________________________ |
| Dermatitis herpetiformis |
|
|
______________________________________ |
| Diabetes mellitus |
|
|
______________________________________ |
| Thyroid disease |
|
|
______________________________________ |
| Arthritis |
|
|
______________________________________ |
| Osteoporosis |
|
|
______________________________________ |
| Stomach/duodenal ulcer |
|
|
______________________________________ |
| Irritable bowel syndrome |
|
|
______________________________________ |
| Colon cancer |
|
|
______________________________________ |
| Other cancer |
|
|
______________________________________ |
| Other chronic disease |
|
|
______________________________________ |
|
|
| Notes and Comments: |
| _______________________________________________________________________ |
| _______________________________________________________________________ |
| _______________________________________________________________________ |
| _______________________________________________________________________ |
| _______________________________________________________________________ |
| _______________________________________________________________________ |
