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Celiac Disease Symptoms Checklist

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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 to your child.

Note: Some individuals with celiac disease do not have any outward symptoms. Individuals with certain risk factors, like having a family member with celiac disease, should be tested even if symptoms are not present.

Be sure to click the continue button after you have submitted the form

 
I (or my child) frequently experience:







I (or my child) have been diagnosed with the following illnesses or conditions:







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.
After submitting your form, scroll to the bottom of the next page and print the 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.

 
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