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CELIAC DISEASE SYMPTOMS AND CONDITIONS CHECKLIST

January 30th, 2016 | by h4uclinic
CELIAC DISEASE SYMPTOMS AND CONDITIONS CHECKLIST
Managing Diabetes
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CELIAC DISEASE SYMPTOMS AND CONDITIONS CHECKLIST

 

Celiac Disease Foundation

Most people with celiac disease are undiagnosed. This checklist helps you document for your physician if you or your child have any of the common symptoms or conditions of celiac disease.

Share your checklist responses with your physician to determine if you or your child should have the celiac disease panel blood test.

This checklist is NOT a self-diagnosis tool. Diagnosis of celiac disease requires a celiac disease panel blood test and an endoscopic biopsy of your small intestine. You MUST be eating gluten in order for the celiac disease panel test to be accurate as it measures your body’s reaction to gluten. A proper diagnosis can only be made by a physician.

INSTRUCTIONS: For you or your child, select the symptoms and conditions that apply and their frequency where indicated.  Hover your mouse over each blue tool tip icon for a more detailed description.

General Conditions

  • Anemia

YesNoUnsure

  • Fatigue or Chronic Fatigue Syndrome

YesNoUnsure

  • Failure to Thrive

YesNoUnsure

  • IgA Deficiency

YesNoUnsure

  • Malnutriton or Vitamin Deficiency

YesNoUnsure

 

Behavioral or Central Nervous System Conditions

  • ADHD

YesNoUnsure

  • Anxiety

YesNoUnsure

  • Brain Fog or Foggy Mind

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Depression

YesNoUnsure

  • Developmental Delay

YesNoUnsure

  • Headache or Migraine

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Irritability

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Lack of Muscle Coordination (Ataxia)

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Seizure

YesNoUnsure

 

Gastrointestinal Conditions

  • Abdominal Pain

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Acid Reflux (Heartburn)

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Bloating

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Constipation

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Diarrhea

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Gas

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Lactose Intolerance

YesNoUnsure

  • Lymphoma or Intestinal Cancer

YesNoUnsure

  • Pale, Foul-Smelling Stool

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Unexplained Liver Problem

YesNoUnsure

  • Vomiting

NeverDailyWeeklyMonthlyOnce in a WhileUnsure

  • Weight Loss or Weight Gain

YesNoUnsure

 

Muscular Skeletal Conditions

  • Arthritis

YesNoUnsure

  • Bone or Joint Pain

YesNoUnsure

  • Fibromyalgia or Muscle Pain

YesNoUnsure

  • Numbness or Pain in Hands and Feet (Peripheral Neuropathy)

YesNoUnsure

  • Osteopenia or Osteoporosis

YesNoUnsure

  • Short Stature

YesNoUnsure

 

Reproductive Conditions

  • Delayed Puberty

YesNoUnsure

  • Infertility

YesNoUnsure

  • Menstrual Irregularities or Missed Periods

YesNoUnsure

  • Miscarriage

YesNoUnsure

 

Skin and Dental Conditions

  • Discolored Teeth or Enamel Loss

YesNoUnsure

  • Eczema

YesNoUnsure

  • Itchy Skin Rash (Dermatitis Herpetiformis)

YesNoUnsure

  • Loss of Hair from your Head or Body (Alopecia)

YesNoUnsure

  • Recurrent Mouth Canker Sores/Oral Ulcers (Aphthous Stomatitis)

YesNoUnsure

 

Other Conditions and Autoimmune Disorders

  • Please mark any diagnosed conditions:

Autoimmune HepatitisAddison’s DiseaseCrohn’s Disease; Inflammatory Bowel DiseaseChronic PancreatitisDown SyndromeIdiopathic Dilated CardiomyopathyIgA NephropathyIrrtitable Bowel Syndrome (IBS)Juvenile Idiopathic ArthritisMultiple SclerosisPrimary Biliary CirrhosisPrimary Sclerosing CholangitisPsoriasisRheumatoid ArthritisSclerodermaSjogren’s DiseaseThyroid DiseaseTurner SyndromeType I DiabetesUlcerative Colitis; Inflammatory Bowel DiseaseWilliams SyndromeNone

 

Family Member

  • 1st Degree Relative with Celiac Disease (Parent, Sibling, Child)

YesNoUnsure

  • 2nd Degree Relative with Celiac Disease (Aunt, Uncle, Grandparent, Niece, Nephew, Cousin or Half-Sibling)

YesNoUnsure

 

Diet

  • Currently Eating a Diet Containing Gluten (Wheat, Rye, Barley)

YesNoUnsure

 

Submitted By

  • To receive a copy of your Symptoms Checklist to share with your physician, please enter the information below. Once received, print from your email browser. IMPORTANT: Celiac Disease Foundation does NOT disclose your contact information to third parties. Please review our Terms of Use and Privacy Policy for additional information.
  • First Name *This field is required.
  • Last Name *This field is required.
  • Email *This field is required.
  • Zip Code *This field is required.

 

Verification

  • Please enter any two digits *This field is required.

Bottom of Form
Read more at https://celiac.org/celiac-disease/

 

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