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* 1. Please provide your contact information.

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* 2. What is your gender?

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* 3. In what category is your age?

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* 4. Have you received a diagnosis of celiac disease from a healthcare provider?

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* 5. How long did it take from your first symptoms to receive a diagnosis?

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* 6. What year were you diagnosed?

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* 7. Of all the symptoms that you experience because of celiac disease, which 1-3 symptoms have the most significant impact on your life?

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* 8. Are there specific activities that are important to you but that you cannot do at all or as fully as you would like because of celiac disease? If so, please list them in the comments section.

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* 9. How do your symptoms and their negative impacts affect your daily life?

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* 10. How have your symptoms changed over time?

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* 11. Do your symptoms come and go or are they ongoing?

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* 12. For how long do you feel negative symptoms if you've been exposed to gluten?

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* 13. What worries you most about having celiac disease?

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* 14. Have you adopted a strict gluten-free diet?

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* 15. What are the barriers to adopting a strict gluten-free diet?

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* 16. What specific symptoms does the gluten-free diet mitigate for you?

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* 17. On a scale from 1-5, with 1 being not well and 5 being very well, how well does the gluten-free diet treat your most significant symptoms?

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* 18. On a scale from 1-5, with 1 being not well and 5 being very well, how well does the gluten-free diet improve your ability to do specific activities that are important to you in your daily life?

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* 19. Assuming there is no complete cure for celiac disease, what specific things would you look for in an ideal treatment for your condition?

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