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

This is a request for a survey response>

All information will remain strictly confidential

The Celiac Disease Foundation is cooperating with a well-published
gastroenterologist on a paper related to diagnosis of atypical celiacs
to be presented at the 2001 October annual meeting of the American
College of Gastroenterologists..

Much of the data being used is data from the files and responses to new
member surveys of the Celiac Disease Foundation. What is lacking is
quantifiable data related to patient symptoms at the time of diagnosis.

MUST BE BIOPSY-DIAGNOSED CELIAC and/or DH TO RESPOND

Please complete the following survey data by highlighting and copying
this e-mail to an e-mail reply addressed only to:
[log in to unmask]

Put an "x" ONLY before those symptoms listed below that you were
experiencing during the period of your diagnosis.

Patient or Guardian's Name:

Mailing Address Street/Box:

City/State/Zip:

(   ) Gender M or F:
(   ) Age at Diagnosis (years):
(   ) Diagnosed CD (celiac disease, celiac sprue, gluten-sensitive
         enteropathy, non-tropical sprue)
(   ) Diagnosed DH (dermatitis herpetiformis)

(   ) Had NO symptoms at time of diagnosis

Please tell us your symptoms when you were first diagnosed with celiac
disease as defined by the following questions:

What were your bowel habits?
(   ) normal?
(   ) varied with both diarrhea and constipation?
(   ) mostly diarrhea?
(   ) mostly constipation?


Did you have abdominal pain?
(   ) none?
(   ) infrequent?
(   ) frequent?

If you had abdominal pain or discomfort was it (   ) relieved by passing
a bowel movement? (   ) onset related to frequency of stools (either
diarrhea or constipation)? (   ) onset related to change in form of
stool (loose, watery or hard)?

Did you have
(   ) anemia?
(   ) weight gain?
(   ) weight loss?
(   ) gas or bloating?
(   ) fatigue or tiredness?
(   ) nausea, cramping or vomiting?
(   ) muscle, joint or bone pain?
(   ) failure to grow to normal height (short stature)?
(   ) hair loss?
(   ) rash?
(   ) depression or irritability or anger?
(   ) confusion or loss of memory?

Did your doctor tell you that you had
(   ) fibromyalgia?
(   ) chronic fatigue syndrome?
(   ) irritable bowel syndrome?
(   ) anxiety, depression or stress?

Please tell us any other symptoms that you had when you were diagnosed
with celiac disease or DH.

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We thank you for your participation
Celiac Disease Foundation

We suggest you visit our website as it is under continual update,
especially if you have not seen it recently.

http://www.celiac.org