Patient Name:
DOB:
Date:
Deva Health, PLLC
Celiac Disease Symptom Checklist
Please place a check next to all that apply:
 ___ first degree relative (parent, child, sibling) with Celiac Disease.
 ___ second degree relative (aunt, uncle, cousin) with Celiac Disease.
 ___ lactose intolerance
 ___ excessive gas
 ___ fatigue (tired all the time)
 ___ indigestion (dyspepsia)
 ___ reflux (GERD)
 ___ frequent diarrhea or foamy diarrhea
 ___ constipation
 ___ alternating diarrhea and constipation
 ___ stearorrhea (oily or greasy stools)
 ___ pale, foul-smelling, bulky stools
 ___ abdominal pain
 ___ abdominal distention/bloating
 ___ inability to concentrate
 ___ fuzzy-minded
 ___ bleed easily
 ___ nose bleeds
 ___ persistent itchy rash
 ___ mouth sores or cracks in the corners of the mouth
 ___ dry mouth or dry eyes
 ___ muscle cramping
 ___ night blindness
 ___ tooth enamel defects (cavities, discoloration, tooth enamel loss)
 ___ lack the desire to eat
 ___ vitamin deficiencies
 ___ iron deficiency anemia, unexplained
 ___ decreased ability for my blood to clot
 ___ generalized weakness
 ___ weight loss
 ___ under weight
 ___ bone pain
 ___ joint pain
 ___ easily fractured bones (osteoporosis, osteopenia)
Patient Name:
DOB:
Date:
 ___ abnormal or impaired skin sensation (parasthesia), including burning, prickling,
itching or tingling
 ___ unexplained edema (swelling)
 ___ pale
 ___ wasted buttocks (decreased muscle mass in buttocks)
 ___ short stature/growth retardation
 ___ amenorrhea (missed menstrual periods)
 ___ bone disease
 ___ unable to conceive/impregnate
 ___ chronic fatigue syndrome
 ___ fibromyalgia
 ___ irritable bowel syndrome (IBS)
 ___ depression
Diseases Linked to Celiac Disease
People with celiac disease tend to have other autoimmune diseases as well.
 ___ rheumatiod arthritis
 ___ dermatitis herpetiformis
 ___ autoimmune thyroid disease (such as Graves' disease or Hashimoto's thyroiditis)
 ___ inflammatory bowel disease (IBD) (such as Crohn's disease, or ulcerativitis
hepatitis)
 ___ systemic lupus erythematosus
 ___ insulin-dependent diabetes mellitus (type 1 or juvenile diabetes)
 ___ autoimmune liver disease (such as primary biliary cirrhosis or autoimmune
hepatitis)
 ___ collagen vascular disease (examples: periarteritis nodosa, scleroderma,
dermatomyositis, polyarteritis nodosa)
 ___ Sjogren's syndrome
No Symptoms - some people have mild celiac disease without noticeable symptoms. Nonspecific symptoms - some people get mild but unclear symptoms.