Below is a 15 question screening tool to help identify if your child is at high risk for celiac disease. It takes less than 5 minutes to complete and score but can make a lifetime of difference in the health of your child and your family’s quality of life.
How accurate is the screening questionnaire?
Research has concluded that the questionnaire is 87% effective in identifying children at high risk for celiac disease. However, the questionnaire results are not a medical diagnosis and the screening program does not replace a comprehensive exam by a trained physician.
Does the questionnaire recommend treatment?
No, the celiac disease screening questionnaire only identifies children who are at high risk for the disease. If a child is identified at high risk it is recommended you consult a local and knowledgeable health care professional for further medical evaluation and testing.
Questionnaire for Celiac Disease Screening
Age: _____
Sex: _____
Please tell us how often your child has any of the following by circling the best answer.
Total Score:____________
Scoring: Never=1; Seldom= 2; Frequent=3; A Lot=4; Don’t Know=0; No=1; Yes=2
1. Abdominal pain, gas or bloating? (STOMACH)
Never Seldom Frequent A Lot Don’t Know
2. Diarrhea, constipation, vomiting or nausea? (INTESTINAL)
Never Seldom Frequent A Lot Don’t Know
3. Allergies or asthma? (ALLERGIES)
Never Seldom Frequent A Lot Don’t Know
4. Short stature, growth delay, or weight loss? (GROWTH)
Never Seldom Frequent A Lot Don’t Know
5. Fatigue, weakness, anemia or other nutrient deficiencies? (ANEMIA)
Never Seldom Frequent A Lot Don’t Know
6. Unexplained mood swings, depression, anxiety or stress? (MENTAL)
Never Seldom Frequent A Lot Don’t Know
7. Unexplained headaches, joint aches or body aches? (ACHES)
Never Seldom Frequent A Lot Don’t Know
8. Dental enamel defects (vertical or horizontal grooves in permanent teeth that are chalky white) or recurring canker sores in mouth? (MOUTH)
Never Seldom Frequent A Lot Don’t Know
9. Skin rashes such as eczema, psoriasis, or dermatitis herpetiformis (itchy, blistering skin) (SKIN)
Never Seldom Frequent A Lot Don’t Know
10. Any autoimmune syndrome such as IgA deficiency or autoimmune thyroiditis (AUTOIMMUNE)
No Yes Don’t Know
11. Type I diabetes (DIABETES)
No Yes Don’t Know
12. Down’s syndrome, Turner’s syndrome, or William’s syndrome (SYNDROME)
No Yes Don’t Know
13. Autism, hyperactivity, learning disabilities or attention deficit disorder (COGNITIVE)
No Yes Don’t Know
14. A first degree relative with diagnosed celiac disease (RELATIVE)
No Yes Don’t Know
15. Higher than normal absenteeism due to sickness (more than 15 days) (ABSENTEEISM)
No Yes Don’t Know
Scoring:
A score greater than 24 indicates a child at high risk for celiac disease.
>24 indicates a child at high risk for celiac disease
Categories in parentheses indicates factors for risk. For example abdominal pain, gas or bloating correlate to stomach symptoms.
