<<Disclaimer: Verify this information before applying it to your situation.>>

CELIAC DISEASE
TIMELY DIAGNOSIS SURVEY

The purpose of this survey is to obtain your opinion on the timely diagnosis
of Celiac Disease (CD) by medical professionals.  Celiac Disease (CD) is also
called non-tropical sprue, celiac sprue, and gluten sensitive enteropathy
(GSE).

If you are a member of a CD support group, please share the survey with other
members, who may not have access to a computer and modem.

1. Enter date you (or your child) first experienced symptoms of CD (mm/yy).
Example:  03/82.
____________________________________________________________________

2. List symptoms you (or your child) experienced.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

3. Enter date you (or your child) were diagnosed with CD (mm/yy).
____________________________________________________________________

4. What city, state and country do you live in?  Example: Baltimore, MD, USA
____________________________________________________________________

 5. How was your CD diagnosis confirmed?
      A. Blood Tests   B.Small Bowel Biopsy    C.Skin Biopsy    D.Gluten-free
Diet
      E. Other, please explain:
____________________________________________________________________

6. In your opinion, what reasons prevented you from receiving a more timely
diagnosis of CD?
A. Not applicable, I received a timely diagnosis (within three consecutive
visits, and within three months).
B. I did not receive a timely diagnosis because:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

7. List other diagnosed diseases you (or your child) have, and the date of
diagnosis (mm/yy).
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________


Thank you for your participation.

A summary of survey results will be posted in March 1998. Respondents must
return their surveys by Feb 15, 1998.  Return the survey to:  [log in to unmask]
Printed surveys can be mailed to M.G.Kapps, 11505 Snowden Pond Rd., Laurel, MD
20708.