Celiac Disease Questionnaire

Thank you for your interest in learning more about our clinical research opportunities. See if you may qualify by answering a few short questions. By filling out the interest form below, you consent to being contacted by our patient enrollment specialists via phone, text, or email with more information.

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Camp ID

First Name

Last Name

Select Gender

Gender

Date of Birth

Date

Language

Current Date

Date

Age

Primary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Secondary Phone Number

Please enter a valid phone number.Format: (000-000-0000).

Email

example@example.com

Metro Area

Zip Code

Metro Code

SiteId

State ID

CampRefID

Race

Ethnicity

Weight

Feet

Inches

Calculated BMI

Do you have a history of celiac disease not responding to a gluten-free diet for at least 1 year?

Are you currently experiencing any of the following symptoms that you attribute to your celiac disease? (Check all that apply - need to report at least one symptom to qualify)

Have you undergone a biopsy or blood test to establish your history of celiac disease?

Are you currently taking probiotics for the management of your celiac disease?

Eligibility Status