<<Disclaimer: Verify this information before applying it to your situation.>>
Dear List members,
I ask those of you who are not celiacs and have no serious problems
with health to participate in this study. This is necessary to compare
CD patients with a control group. I need people aged above 25.
Thank you.
Michail Valivach, MD, Pavlodar, Kazakhstan.
In SUBJECT, please, note "QUESTIONS 2"
Thank you very much,
Michail Valivach, MD
Questions
1. Name (or pseudonym). Sex.
2. Birth date
Stature
Weight
3. How long have you been GF?
4. Do you have chronic (lasting more than 2 months) of frequent (more
than 4 episodes in a year) infectious and noninfectious inflammatory diseases?
Yes, No, I can not answer
If "Yes", please answer the following questions:
a. Do you have chronic or frequent respiratory infections?
Yes, No, I can not answer
If so, are you easily infected during epidemics
Yes, No, I can not answer
and/or you have your own chronic or relapsing infection
(for instance, chronic bronchitis, tonsillitis etc)
Yes, No, I can not answer
List the infections:
b. Do you have or had asthma?
Yes, No, I can not answer
5. Do you have any skin diseases?
Yes, No, I can not answer
If "Yes", please, list their diagnoses:
6. Are you predisposed to allergic reactions?
Yes, No, I can not answer
If "Yes", please, give more information
7. Do you have any diseases of the digestive system (additionally
to CD)?
Yes, No, I can not answer
Please, list them:
9. The highest body temperature during the last 3 years:
10. Are you predisposed to long lasting (more than 14 days) fever?
Yes, No, I can not answer
11. Fatigue
12. Please, describe you skin. Do you have:
a. Constant or episodic hair loss
Yes, No, I can not answer
b. Dry or tarnished hair
Yes, No, I can not answer
c. Early turning gray (before 30)
Yes, No, I can not answer
d. Predisposition to dandruff
Yes, No, I can not answer
e. Fragility of the nail walls
Yes, No, I can not answer
f. Fragility of the nails
Yes, No, I can not answer
g. Dryness of the lips
Yes, No, I can not answer
h. Cyanosis of the lips
Yes, No, I can not answer
i. General skin dryness
Yes, No, I can not answer
j. Dryness and/or scaling and/or irritation
- in the nasolabial region
Yes, No, I can not answer
- of the elbows and/or knees
Yes, No, I can not answer
- above the brows (including dandruff) and/or around the eyes
Yes, No, I can not answer
- of the hands (especially after water exposure)
Yes, No, I can not answer
- of the cheeks
Yes, No, I can not answer
- of the nose
Yes, No, I can not answer
- of the ears
Yes, No, I can not answer
k. Follicular hyperkeratosis (perifollicular accentuation). That
means small dry skin elevations around the hair follicles.
Yes, No, I can not answer
l. Cyanotic, marbled skin
Yes, No, I can not answer
m. Scaling dermatitis (like eczema)
Yes, No, I can not answer
n. Red spots with dryness and/or scaling and/or irritation
Yes, No, I can not answer
o. Predisposition to acne (black heads)
Yes, No, I can not answer
p. Bad tolerance to sun burns
Yes, No, I can not answer
q. Skin itching
Yes, No, I can not answer
r. Chronic skin candidiasis (yeast infection)
Yes, No, I can not answer
s. Feet cyanosis
Yes, No, I can not answer
t. Patch-shaped foci of hyperkeratosis (foci of dry and thick skin)
Yes, No, I can not answer
13. Please, describe the tongue:
a. Enlarged tongue with the teeth imprints
Yes, No, I can not answer
b. Smooth ("polish") tongue
Yes, No, I can not answer
c. Hypertrophy of the tongue papillae (small round elevations)
Yes, No, I can not answer
d. Dry bright-red tongue
Yes, No, I can not answer
e. Cracks or folds on the tongue
Yes, No, I can not answer
f. Irritation and/or brown cover of the tongue base
Yes, No, I can not answer
g. Dryness of the mucous membranes
Yes, No, I can not answer
h. Gum bleeding after teeth brushing
Yes, No, I can not answer
14. Gastrointestinal tract:
a. Unpleasant smell from the mouth
Yes, No, I can not answer
b. Pains in the tip of the stomach
Yes, No, I can not answer
c. Heartburn
Yes, No, I can not answer
d. Sour and/or bitter and/or nasty belch
Yes, No, I can not answer
e. Unpleasant sensations below the ribs on the right
Yes, No, I can not answer
f. Unpleasant sensations below the ribs on the left
Yes, No, I can not answer
g. Pains in the upper abdomen or nausea on fasting
Yes, No, I can not answer
h. Feeling bloated after moderate amounts of food
Yes, No, I can not answer
i. Intestinal murmur after food
Yes, No, I can not answer
j. Intestinal murmur after milk
Yes, No, I can not answer
k. Hemorrhoids
Yes, No, I can not answer
l. Liquid or semi-liquid stool very often
Yes, No, I can not answer
m. Intensive urges to defecate
Yes, No, I can not answer
n. Stool leaves traces on the lavatory bowl
Yes, No, I can not answer
o. Undigested food in stool very often
Yes, No, I can not answer
p. Fragmented ("sheep's") stool
Yes, No, I can not answer
q. Constipation
Yes, No, I can not answer
r. Stool with sour smell
Yes, No, I can not answer
s. Stool with rotten smell
Yes, No, I can not answer
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