Are You Sensitive To Gluten-Containing Food?

Are You Sensitive To Gluten-Containing Food? — Dr. Shabnam Das Kar MD

Questionnaire submitted

A confirmation email with your score has been sent to .

You will receive a reminder in 20 days to complete the questionnaire again.
Please bring both scores to your next appointment or share them with your healthcare provider.

This questionnaire lists common symptoms associated with non-coeliac gluten sensitivity. It is designed to help you track whether your symptoms change when you remove gluten-containing foods from your food choices.

Complete the questionnaire and note your total score.
Remove all gluten-containing foods from your food choices for two weeks.
Complete the questionnaire again at the end of those two weeks.
If your score is lower after the two-week period, this suggests that gluten sensitivity may be contributing to your symptoms.

This questionnaire is for educational purposes only and does not constitute a diagnosis. Please discuss your results with a qualified healthcare provider.

Name *

Email address *

Date completed

Which assessment is this? *

Rate each symptom — click a number · 0 = none · 10 = severe · all questions required

Please rate all symptoms before submitting. The unanswered questions are highlighted in red below.

1Abdominal pain or discomfort *

NoneSevere

Please select a number for this symptom.

2Heartburn *

NoneSevere

Please select a number for this symptom.

3Acid regurgitation *

NoneSevere

Please select a number for this symptom.

4Bloating *

NoneSevere

Please select a number for this symptom.

5Nausea and/or vomiting *

NoneSevere

Please select a number for this symptom.

6Intestinal rumbling (gurgling sounds) *

NoneSevere

Please select a number for this symptom.

7Abdominal distension (visible swelling) *

NoneSevere

Please select a number for this symptom.

8Belching *

NoneSevere

Please select a number for this symptom.

9Increased gas/flatulence *

NoneSevere

Please select a number for this symptom.

10Fewer bowel movements than usual *

NoneSevere

Please select a number for this symptom.

11More frequent bowel movements than usual *

NoneSevere

Please select a number for this symptom.

12Loose or watery stools *

NoneSevere

Please select a number for this symptom.

13Hard stools *

NoneSevere

Please select a number for this symptom.

14Urgency to have a bowel movement *

NoneSevere

Please select a number for this symptom.

15Feeling of incomplete bowel emptying *

NoneSevere

Please select a number for this symptom.

16Skin rash (dermatitis) *

NoneSevere

Please select a number for this symptom.

17Headache *

NoneSevere

Please select a number for this symptom.

18Brain fog *

NoneSevere

Please select a number for this symptom.

19Fatigue *

NoneSevere

Please select a number for this symptom.

20Numbness or tingling in the limbs *

NoneSevere

Please select a number for this symptom.

21Joint or muscle pain *

NoneSevere

Please select a number for this symptom.

22Fainting or near-fainting *

NoneSevere

Please select a number for this symptom.

23Mouth or tongue lesions (ulcers or sores) *

NoneSevere

Please select a number for this symptom.

Other symptoms (please specify)

0 / 230

Record this score. Complete the questionnaire again after your 20-day gluten-free period and compare.

Something went wrong. Please try again, or email your score directly to info@drkarmd.com.

Reference: Catassi, Carlo, et al. “Diagnosis of non-celiac gluten sensitivity (NCGS): the Salerno experts’ criteria.” Nutrients 7.6 (2015): 4966–4977.