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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 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 INFORMATION IS COLLECTED IN THE HOPE OF PROVIDING INSIGHT ABOUT THE CELIAC DISEASE COMMUNITY, IMPROVING THE QUALITY OF LIFE FOR PEOPLE WITH CELIAC DISEASE AND FINDING NEW TREATMENTS AND EVEN A CURE FOR CELIAC DISEASE. NFCA WILL NOT DISCLOSE YOUR PERSONAL INFORMATION TO ANY THIRD PARTY. AS CELIAC DISEASE RESEARCH EVOLVES, THERE MAY BE AN OPPORTUNITY TO GAIN GREATER EFFECTIVENESS BY SHARING SOME OR ALL OF THIS INFORMATION AS NFCA COLLABORATES WITH LEADING RESEARCH INSTITUTIONS. 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.

 
 
  • Have you or your family members been diagnosed?
    Complete our celiac disease symptoms checklist today to find out if you are at risk of having celiac disease / gluten intolerance. We can help improve the quality of your life!
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