Questionnaire | Coeliac Worldwide

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Questionnaire

We have designed an online questionnaire to collect vital, new information from people with Coeliac Disease.

It has been designed to be quick to fill in. Most of the questions just need a single word or click of your mouse to complete.

Once you have completed the survey to your satisfaction please press the submit button at the bottom of this page.

Thank you.

01 Age: *

Please supply your age (in years)

01a Are you:

Female

Male

Select one

02 What is your country of residence?:

03 Are you a: *

Medically diagnosed Coeliac

Suspected Coeliac (awaiting results)

Suspected Coelaic (no medical tests yet)

Gluten-intolerant but not Coelaic

Gluten-free diet as a lifestyle choice

Select one

04 Does your family have a history of Coeliac Diease?: *

Please select all that apply. (You can select more than one option by holding down the control key while selecting items with your mouse.)

05 When were you diagnosed?:

At what age

06 At what age did you first experience symptoms?: *

You may have experienced symptoms many years before being diagnosed. Symptoms can appear at any age. For some Coelaics this is in childhood, others adulthood and others can be symptom free. Most people are diagnosed around the age of 40 (UK Statistics).

07 Did the symptoms occur at the same time as a specific event in your life?: *

e.g an illness or infection, a period of stress, overseas travel, antibiotics or medication etc. Do you feel something helped triggered it? Please specify

08 Were you born: *

In Hospital

At Home

Select one

09 Were you a: *

Medication and epidural refer to your mothers use. Please select all that apply. (You can select more than one option by holding down the control key while selecting items with your mouse.)

10 After your birth were you: *

Healthy

Needed hospitalisation and medication

Select one

11 Were you: *

Breast-fed

Bottle-fed

I don't know

Select one

12 If you were breast-fed please specify for how many months:

13 At how many months of age was gluten introduced into your diet?: *

Gluten is found in wheat, rye, barley and possibly oats and their derivatives.

14 Was your mother on antibiotics while: *

Please select all that apply. (You can select more than one option by holding down the control key while selecting items with your mouse.)

15 Did your mother have a bacterial infection, such as thrush, vaginitis, candida etc while: *

Please select all that apply. (You can select more than one option by holding down the control key while selecting items with your mouse.)

16 At what age did you first have antibiotics?: *

Please specify in months, years or I don't know or never

17 Do you have a history of multiple antibiotic use?: *

Yes

Have you taken antibiotics for acne, respiratory, urinary or other infections for 2 months or longer, or for shorter periods of 4 or more times in a 1-year span.

18 If you have a history of antibiotic use you can tell us more here:

E.g.I was first given antibiotics at 6 month for an infection, repeated use during my childhood, in my teens for acne and various times in adulthood, mainly due to bladder infections.

19 Are you on an: *

Exclusive gluten-free diet (no oats)

Exclusive gluten-free diet (I eat oats)

Mostly gluten-free

I include gluten in my diet

Gluten is found in wheat, rye, barley and possibly oats

20 How long have you been on this diet?: *

Please specify in months or years

21 Do you have any food, drink or tobacco cravings or addictions?:

Please select all that apply. (You can select more than one option by holding down the control key while selcting items with your mouse.)

22 What were your symptoms before excluding gluten from your diet?: *

Please select all that apply. (You can select more than one option by holding down the control key while selecting items with your mouse.)

23 Are your symptoms less on a gluten-free diet?:

Symptom free

much less

slightly less

no change

Select one

24 Please tell us your symptoms now, if any:

25 Do you have other complications of Coelaic Disease?: *

Please select all that apply. (You can select more than one option by holding down the control key while selecting items with your mouse.)

26 Do you take?:

Some people feel that even on a healthy diet they don't get all of the goodness and nutrients they need daily.

27 Thank you for filling in this questionnaire. Would you like to be emailed when the results are published?:

Please type in your email address.

We really appreciate your time. Please add any other comments in the space below and click the submit button. Thank you.:

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