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

I am reissuing this survey at the suggestion of several listmembers
since a number missed it in the AD issue at the first of the month. If
you have already answered it it is not necessary to submit again

Also a number of people asked for the easiest mechanics to answer the
questionnaire

To answer this survey
With your mouse
highlight the complete text of the message
Then copy it to your clip board.

Open your new message for the reply
click your mouse in the area of the message
Then paste it in the message area
Address it
then edit the message to insert your answers
then send it to
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The Celiac Disease Foundation is requesting your
assistance. Will you take a few minutes to answer
the following additional questions to our on-going
survey of "atypical presentations"
Responses are requested prior to March 15, 2002
Please send responses to
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INFORMATION QUESTIONNAIRE

As you know many, patients with celiac disease first develop their
symptoms when they are adults.  We are trying to determine what
factors may cause an adult who seems to be healthy to then suddenly
develop celiac disease symptoms.  The Celiac Disease Foundation is
asking for your help by completing this short questionnaire.

All responses will remain confidential and are for the exclusive
use of the celiac disease foundation.

Sex: Male (  )   Female  (  )

(  )  Diagnosed CD (celiac disease, celiac sprue, gluten-sensitive enteropathy)
(  )  Diagnosed DH (dermatitis herpetiformis)

Age that you developed celiac symptoms ______ Yrs (mos = ?/12)

Were they are major events in your life just before or at the time
that you developed celiac disease?  How many months before the
celiac disease was this event? (When in months)

(  )  surgery  type of surgery __________________       When __________
(  )  Emotional or physical trauma  Type_______________ When __________
(  )  Pregnancy                                         When __________
(  )  Stopping smoking                                  When __________
(  )  Starting smoking                                  When __________
(  )  Medications  Type________________                 When __________
(  )  Change in diet Type________________               When __________
(  )  Other events ______________________________________________________
_________________________________________________________________________


For women:  Was the time of onset of celiac disease related to
menopause of use of estrogens?

(  )  Menopause began before celiac                     When _________
(  )  Celiac developed during menopause                 When__________
(  )  At time of starting or stopping estrogens   Explain________
      ___________________________________________________________
      ___________________________________________________________

(  ) Unrelated to menopause or estrogens

For all respondents

Your thoughts on what triggered you to become a celiac:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

The following information is optional(for the respondent) and permits
the researchers to contact you if there are  additional questions
Name______________________________ Phone__________________
Address_________________________________________________________
________________________________________________________________

All responses will remain confidential and are for the exclusive
use of the Celiac Disease Foundation.