Gluten Questionnaire

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Gluten Questionnaire

Gluten intolerance has been found to be most common among people of the Irish, English, Scottish, Scandinavian and Eastern European. Often times it is assumed that gluten intolerance is a food allergy, but it is not. It is actually an autoimmune process which affects an alarming percentage of the population. The most significant symptoms are weight gain, fatigue and depression.

The following test is a diagnostic tool to help you to understand the symptoms and signs that are likely to go along with gluten intolerance.

Call today for a free consultation. World Chiropractic is located in Richmond Virginia on Gaskins Rd. near Patterson Ave. (804)740-3434

Do any of the following apply to you?

Yes	No
		Weight Gain
		Unexplained fatigue
		Difficulty relaxing, feel tense frequently
		Unexplained digestive problems
		Female hormone imbalances (PMS, menopausal symptoms)
		Muscle or joint pain or stiffness of unknown cause
		Migraine like headaches
		Food allergies/sensitivities
		Difficulty digesting dairy products
		Tendency to over consume alcohol
		Overly sensitive to physical and emotional pain, cry easily
		Cravings for sweets, bread, carbohydrates
		Tendency to overeat sweets, bread, carbohydrates
		Abdominal pain or cramping
		Abdominal bloating or distention
		Intestinal gas
		“Love” specific foods
		Eat when upset, eat to relax
		Constipation or diarrhea of unknown cause
		Unexplained skin problems/rashes
		Difficulty gaining weight

Have you suffered from any of the following conditions?

Yes	No
		Allergies
		Depression
		Anorexia
		Bulimia
		Rosacea
		Diabetes
		Osteoporosis/ bone loss
		Iron deficiency/ anemia
		Chronic fatigue
		Irritable bowel syndrome
		Crohn’s disease
		Ulcerative colitis
		Candida
		Hypoglycemia
		Lactose intolerance
		Alcoholism