Patient's CDX Questionnaire

CeliacDx Questionnaire

Please answer the following questions about family history of celiac disease, previous testing for celiac disease (if any) and your health. Your answers will provide our pathologists with the information they need to for ordering your CeliacDx test kit and interpreting the results.

All data you provide is encrypted and will not be shared with outside parties. If review of your symptoms and health history reveals CeliacDx testing is not medically necessary, we will contact you and issue a full refund to your original method of payment. If you are unable to complete the questionnaire, please reach out to our helpdesk

SECTION I: FAMILY HISTORY

Has anyone in your family been diagnosed with celiac disease?
Check all that apply

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