NFCA
Celiac Disease Symptoms Checklist

STEP 1: Complete this Celiac Disease Symptoms Checklist

While the symptoms of celiac vary, suffering from any of these symptoms — especially over time — may indicate that you should ask your doctor for a celiac blood test. Check all that apply to you, or your child.

I (or my child) frequently experience:
_bloating, gas and/or abdominal pain 	
_hard to flush, bulky or loose stools
_diarrhea or constipation 	
_fatigue
_itchy skin rash 	
_tingling or numbness in hands and feet
_discolored teeth or loss of enamel 	
_canker sores
_joint pain 	
_irritability or behavior changes
_significant unexplained weight loss 	
_poor weight gain
_delayed growth 	
_missed menstrual periods
_fractures or thin bones	

I (or my child) have been diagnosed with the following illnesses or conditions:
_Iron deficiency/ anemia 	
_Infertility
_Depression 	
_Osteoporosis or osteopenia
_Type 1 diabetes 	
_Thyroid disease
_Sjogren’s disease 	
_Juvenile idiopathic arthritis
_Irritable bowel syndrome 	
_Intestinal cancer
_Peripheral neuropathy 	
_Down Syndrome
_Turner Syndrome 	
_Williams Syndrome
_Dermatitis herpetiformis
	
_Check if you have an immediate family member who has been diagnosed with an autoimmune condition or celiac.

Frequently experiencing one or more of the symptoms listed, plus being diagnosed with any one of the diseases or conditions listed, may indicate that you have celiac disease.

Complete this form with your answers so you can take this to your doctor.
 
*PLEASE NOTE* ALL DATA COLLECTED IS FOR INTERNAL RESEARCH PURPOSES ONLY, IN HOPES TO HELP PROVIDE INSIGHT INTO THE HEALTH COMMUNITY AND FURTHER RESEARCH TOWARD FINDING A CURE FOR CELIAC DISEASE. WE WILL NEVER SELL YOUR INFORMATION TO ANY THIRD PARTY. BY COMPLETING THE CELIAC DISEASE SYMPTOMS CHECKLIST YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE WITH THE TERMS OF USE AND THE NFCA PRIVACY POLICY.