Celiac Patient Survey

Please take a few minutes to complete this patient survey.  I’m pretty sure it was put out by the University of Colorado.

It does have the option for “stool test” under diagnosis, so don’t be deterred if you don’t have a technical diagnosis.  Just write in the box if it is different.

Thank you.  Everytime we speak up, we create another ripple.

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3 Responses to Celiac Patient Survey

  1. Cassandra says:

    Thanks, I fixed it.

  2. Dallas says:

    Hello!

    I am a gluten intolerant twenty one year old female college student living in Tucson, AZ. For my cultural anthropology class I have chosen to do my semester research project on those who are gluten intolerant and how they create identity for themselves. I would be so grateful if you (or anybody you know that you could forward this to) found the time to fill out this questionnaire and consent form for me. I would need it emailed back by May first to dally@chef.net. Thank you so much and I look forward to your reply!

    -Miss Dallas Scott

    Gluten Intolerance and Identity Questionnaire:

    Where do you live?

    Where do you work and is where you work influenced by having this gluten sensitivity?

    Where do you generally shop for food at?

    Where do you go out to eat?

    Do you generally go out to eat with the same people?

    Does gluten have an effect on where you will and will not go?

    Where do you spend a lot of your time? (home, outdoors, mall, downtown, or like me the kitchen! ect.)

    What kinds of clothing do you wear? fabric types? Brands? What are the reasons you chose for example, cotton gap jeans instead of nike spandex shorts. Again does this relate to your gluten intolerance and issues associated with it (personally I don’t wear acrylic if I “got wheated” and am having a skin reaction because it makes the rash worse..)

    What types of music do you listen to? You can list specific brands.

    Are there any common slogans that you use on anything for example clothing or stickers. (ex: “Beat The Wheat!” Or “Bootin’ The Gluten!” or even “Gluten Free!” like the sticker I have on my car)

    Do you use any slang term specifically related to gluten sensitivity? (like “got wheated”)

    Do you have any other allergies and/or medical conditions?

    What types of doctors do you choose to see and what kinds of treatment (acupuncture, chiropractic care, western allopathic, eastern Chinese, aryuvedic…)

    What kinds and brands of supplements/ medicine do you take?

    Do you seek out friends or wish to date those who are gluten sensitive as well, are you a part of any clubs related to being gluten free?

    Do you want people to know you are gluten sensitive when you first meet or like me do you tell them after they’ve had your cooking ;)

    Could you describe what your reaction and emotions were when you first found out you had a problem with wheat or gluten, and the changes in the following months up until now. Have you found that your thought process has changed in certain ways? How has this changed your life?

    Additional comments?

    Informed Consent Form for Interview for Anthropology Research Project

    Dear Cassandra,
    This interview is being conducted as an assignment for an Anthropology class at Pima College, Tucson, Arizona, under instructor Dianna Repp (Phone:520-206-6067).
    The information gathered will be read by Repp, and returned to the student. No copies will be archived by Repp.

    I, _______________________ (print name), give my permission for this interview to be used for this Anthropology class assignment.

    _____________________________________________ ________________________
    Signature Date

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