Lisa asked me to post a survey for a research paper she is writing. If you have time to help her out, please consider completing the survey.
BACKGROUND: This survey is being conducted to help assess medical community treatment/awareness of Celiac Disease.
INSTRUCTIONS: Please circle your answer after each question. For questions that ask for lists, please list any information that applies. When completed please return to email@example.com . Thank you in advance for filling out this survey.
1. What is your Gender?
A. Male B. Female
2. What is your age?
A. 0-20 B. 21-30 C. 31-40 D. 41-50 E. 51 and older
3. What is your ethnicity?
A. African American B. Asian C. Hispanic D. Native American E. European decent1
4. What is your education level?
A. High School B. Some College C. Associate’s D. Bachelor’s E. Master’s
5. What is your income level?
A. $0 to 30,000 B. $30,000 to 40,000 C. 40,000 to 50,000 D. 50,000 and above
6. Were you diagnosed with Celiac, Celiac Sprue or gluten sensitivity by a doctor or other method2?
A. Doctor B. Other
7. Did/do you have the classis symptoms: weight loss and chronic diarrhea?
A. Yes B. No
8. Did/do you have any other symptoms? Please list all
17. Have they been diagnosed with any other autoimmune diseases’? (Diabetes Type 1, thyroid or liver disease, anemia or others)
A. Yes B. No ________________________________________________________________________________________________________________________________________________________________________________________________________________________
18. How long from the time the symptoms first appeared did it take to get a diagnosis? (by a doctor or other method2)
A. 0-1 yr B. 1-2 yrs C. 2-5 yrs D. 5 or more years
19. Did the doctor perform a blood test to conform Celiac?
A. Yes B. No C. If yes was it positive? _________________
20. If you answered yes to question 11, did the doctor perform a small intestine biopsy?
A. Yes B. No C. If “No” why not?
21. This area is for any other information that you wish to supply.
Notes 1 European decent includes Italian, English, Irish, French, German, Russian and Canadian French 2 Other Method means any other method than by doctor. This can include adhering to a gluten-free diet and symptoms abating.