Is your child at risk for Celiac Disease?
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. Â 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;Â 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) Â (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.
