<<Disclaimer: Verify this information before applying it to your situation.>>
Dear Fellow Celiacs:
Wheat and other starches are sometimes used as fillers and binders in pharmaceutical products. We are trying to determine if these small amounts of gluten in prescription drugs, over-the-counter non-prescription drugs, and in nutritional supplements cause symptoms in patients with celiac disease and/or dermatitis herpetiformis.
We are inviting you to participate in a survey of your experienced reactions to medications and nutritional supplements.
Your answers are strictly confidential. Only statistical summaries may be presented in scientific forums. All individual identifying information will be kept in strict confidence and not released by the Celiac Disease Foundation or the investigators.
This project has been approved by the Human Subjects Committee, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center.
For those who receive the LISTSERV in digest format, to reply I suggest you highlight this email, COPY and PASTE to a new email and then edit the survey to enter your responses
For those who receive this as a single email just REPLY and enter your responses
Please send your response back to the sender at this address [log in to unmask]
1. Do you suspect that you suffered from any wheat-like reactions to prescription medications prescribed by your physician?
Please list the brand name if possible. If you don’t know the name, please list the type of medicine such as blood pressure pill.
Medications:
Reaction: a) Diarrhea (Y/N), b) Abdominal pain (Y/N), c) Rash (Y/N),
d) Other symptoms:
Other medications or comments:
2. Do you suspect that you suffered from any wheat-like reactions to over-the-counter non-prescription medications (e.g. cold remedies, laxatives, pain pills)?
Non-prescription medications:
Reaction: a) Diarrhea (Y/N), b) Abdominal pain (Y/N), c) Rash (Y/N),
d) Other symptoms:
Other non-prescription medications or comments:
3. Do you suspect that you suffered from any wheat-like reactions to nutritional supplements (e.g. protein drinks, herbal remedies)?
Nutritional supplement:
Reaction: a) Diarrhea (Y/N), b) Abdominal pain (Y/N), c) Rash (Y/N),
d) Other symptoms:
Other nutritional supplements or comments:
4. How do you rate your sensitivity to wheat products?
a. Severe (e.g. immediate diarrhea or abdominal pain with any wheat ingestion) _____Y/N
b. Moderate (e.g. gradual onset such as anemia, but not immediate diarrhea or pain) _____Y/N
c. Mild (e.g. no obvious symptoms) _____Y/N
c. Other
5. Have you been diagnosed by a Physician as having CD or DH? _____Y/N
Biopsy proven? _____Y/N Diagnosed by other health professional? _____Y/N
Sex___ M/F
Age 1st symptoms____(yrs)
Age 1st diagnosed____(yrs)
Years on gluten-free diet_____(yrs)
Other allergies or intolerances? ______________________________________________
Please email back to [log in to unmask]
We greatly appreciate your participation.
Thank you,
Donald Baisch
Celiac Disease Foundation
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