Gluten Intolerance Questionnaire

www.DepkeWellness.com

Gluten intolerance has been found to be most common among people of 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 questionnaire is an assessment tool to help you to understand the symptoms and signs that are likely to go along with gluten intolerance.

Do any of the following currently apply to you? Not necessarily in the moment, but during this time of your life.

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

Have you suffered from any of the following conditions at any point in your life?

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

Test Interpretation Guide (combine both sections)
Number of “Yes” Responses

Potential for Gluten Intolerance

4 or less = Not likely

5 – 8 = Suspected

9 or more = Very likely

A special thank you to Dr. Daniel Kalish for the use of this questionnaire.
Dr. Daniel Kalish
www.drkalish.com
800.616.7708
2105 Industrial Court, Vista, CA 92081