Gluten-Free Diet Assessment Form
Full Name
Age
Contact Information
Reason for Gluten-Free Diet
Celiac Disease
Gluten Sensitivity
Wheat Allergy
Other
Do you have a medical diagnosis?
Yes
No
How long have you been on a gluten-free diet?
Symptoms before starting diet (if any)
Current symptoms (if any)
Biggest challenges with gluten-free diet
Typical foods eaten in a day
Other Information or Questions