celiac survey from middle school student

[Guest guest]

Please complete my survey for my science project on Celiac disease.

(If you are completing the project for your child, please remember that " you "

refers to the

person with celiac disease.)

1. In what year were you born?

2. What age were you when you first started showing symptoms of celiac disease?

3. At what age were you diagnosed with this disease?

4. What do you think triggered celiac disease for you?

5. Do you live near a bakery?

6. Have you or a household member ever worked at one of the jobs below?

Check all that apply.

O Pet store O Bakery O Grocery store O Plant nursery

O Farm O Veterinarian

7. What were your hobbies before celiac disease?

8. Describe the area in which you live.

O Desert O Forest O Suburban O City

O Lakeside O Other, please describe _______________________

9. Describe your neighborhood. Please fill in the dot that applies.

O Apartment O Townhouse O Farm

O Houseboat O Trailer O Other, please describe _____________________

10. About how often was your bedroom vacuumed or the floor cleaned before you

were

diagnosed with celiac disease? __________________________

11. About how many hours or minutes per day do you keep your bedroom window (or

windows) open in warm weather? ________________

in cold weather? ____________________

12. Does anyone else in your family have celiac disease? If so, what is the

person's

relationship to you? ______________________________________________

13. I would like to know about pets that you have had or still have. Please

fill out this

table: (add text on another page if necessary)

What animal was it? How many were there? How long did you have the pet?

How old were you? Who took care of it? Where did it sleep?

14. If you took care of a pet, what did you do to take care of it and for which

pet?

15. Please describe the types of food your pet ate. If your pet ate food that

you bought, if

you remember the brand name, please list it.

___________________________________________________________

14. Are you allergic to anything other than gluten? Please describe.

_________________________________________________________________

15. Does your family (that you live with) have animals other than pets? If so,

please

describe the type of animals, how many of each kind (approximately), when your

family

had them, and where were they kept. _____________________________

_________________________________________________________________

_________________________________________________________________

16. Have you ever slept with your pet or an animal in the same room? If so,

please

describe the pet or pets, time periods, and sleeping arrangement: _____________

_________________________________________________________________

_________________________________________________________________

If you would like to receive the summarized results of this survey, please let

me know your

name and email or mailing address.

Thank you very much for helping with my science project!

L. Sakov, 722 Elm St., San , CA 94070 (650) 802-8697, (Central

Middle

School, San , 6th grade) sarahsakov@...