Miami Holistic Center

Gluten Sensitivity Questionnaire

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For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).   


Address       City 
Birthday:    Month    Day    Year  
SEX:   Male        Female

Gluten intolerance has been found to be most common among people of Irish, English, Scottish, Scandinavian, and Eastern European. Often times it is assumed that gluten intolerance is a food allergy, but it is not. It is actually an autoimmune process, which affects an alarming percentage of the population. The most significant symptoms are weight gain, fatigue and depression.

The following test is a diagnostic tool to help you to understand the symptoms and signs that are likely to go along with gluten intolerance.

Test Interpretation Guide (combine both sections)

Number of “Yes” Responses Potential for Gluten Intolerance  

Potential for Gluten Intolerance

4 or less    = Not likely
5 – 8   =  Suspected
9 or more    = Very likely

Do any of the following apply to you?
Yes   No
  Weight gain
  Unexplained Fatigue
  Difficulty relaxing, feel tense frequently
  Unexplained digestive problems
  Female hormone imbalances, (PMS, menopausal symptoms)
  Muscle or joint pain or stiffness of unknown cause
  Migraine like headaches
  Food allergies/sensitivities
  Difficulty digesting dairy products
  Tendency to over consume alcohol
  Overly sensitive to physical and emotional pain, cry easily
  Cravings for sweets, bread, carbohydrates
  Tendency to overeat sweets, bread, carbohydrates
  Abdominal pain or cramping
  Abdominal bloating or distention
  Intestinal gas
  “Love” specific foods
  Eat when upset, eat to relax
  Constipation or diarrhea of no known cause
  Unexplained skin problems/rashes
  Difficulty gaining weight
Have you suffered from any of the following conditions?
Yes   No
  Osteoporosis/bone loss
  Iron deficiency/anemia
  Chronic fatigue
  Irritable Bowel Syndrome
Crohn’s disease
Ulcerative Colitis

Lactose Intolerance



Clicking on the submit button will e-mail a copy of your Gluten Questionnaire to Miami Holistic Center.>

A Brief Explanation of Gluten Intolerance

As stated above, gluten intolerance is an autoimmune process, and not a food allergy. It is most common among people of Irish, English, Scottish, Scandinavian, and Eastern European. The most common symptoms include, but are not limited to: weight gain, fatigue and depression.

A person with gluten intolerance cannot digest the protein portion of many commonly eaten grains. When this protein is ingested it combines with the enzyme transglutaminase to form an immune complex that deposits on the lining of the intestines. The body recognizes this as a foreign substance, and begins an immune reaction to the complex. Immune cells come into the area and release a series of toxins to try to “kill” this unidentified immune complex. These toxins from the immune system cause inflammation in the digestive system and damage the lining tissue. This is what causes the unexplained digestive symptoms like bloating, diarrhea, constipation, gas, and cramping. The toxins are also responsible for feelings of fatigue and malaise after a meal containing these foods.

The walls of the digestive tract are lined with immune cells that form a protective barrier called Secretory IgA. This lining protects against infectious agents such as bacteria, parasites, and fungus. If a person with gluten intolerance continues to eat the gluten, in time the constant inflammation and irritation in the digestive tract wears away the Secretory IgA. This depletion of immune cells makes a person very susceptible to infectious agents it would normally be able to fight off. The inflammation also begins to damage the small intestine. This affects the person’s ability to absorb the nutrients they need. You quite literally are what you eat and if your body isn’t able to properly absorb your food, you will suffer a myriad of symptoms.

The number one symptom associated with mal-absorption resulting from gluten intolerance is a combination of fatigue and weight gain. If you are not properly absorbing your food you will not be getting any of the nutrients from the food you eat. This will leave you constantly hungry and endlessly tired. Without proper absorption of nutrients, mineral and vitamin deficiencies can develop. Muscle cramping is a common symptom that can arise. The lack of magnesium impairs muscle contraction. Magnesium deficiency has also been linked to cardiovascular disease. An inability to absorb calcium can lead to osteoporosis. Mineral deficiency can also create feelings of restlessness and an inability to relax. It can also make seep difficult and create insomnia. If you cannot absorb your B vitamins you will develop weakness, fatigue, and malaise. If you cannot absorb fats then you cannot control inflammation and since most hormones are made from cholesterol, you will not have the building blocks to synthesize hormones. This among other things can create hormone imbalances, interfering with your ability to handle stress and maintain a balanced emotional state. This also contributes to weight gain in a substantial way. Your hormones have a large effect on your metabolism and your ability to process fat and carbohydrates. Imbalance in insulin will eventually lead to diabetes.

 There is also a phenomenon that causes people to crave things that they are allergic to. There are many theories as to why this happens and the exact mechanism is not yet fully understood. But this is the reason why many people crave carbohydrates or become “addicted” to them much the way an alcoholic becomes addicted to alcohol.

There are cells lining the intestinal tract that create enzymes to digest food. They too are damaged in this process. If the body cannot secrete the enzyme lactase, lactose can no longer be digested and the person becomes intolerant to dairy. They may also lose their ability to digest protein - which can lead to a deficiency in amino acids. Amino acids are the building blocks for neurotransmitters, one of which is Serotonin. Low levels of Serotonin have been medically linked to problems with depression and insomnia.

Eventually the digestive tract develops gaps in areas of constant inflammation. This condition is referred to as leaky gut syndrome. When this occurs, these immune complexes form the gluten reaction - other food particles, parasites, bacteria, viruses, fungi and any other invaders can exit the GI tract and enter the blood stream. This increases the body’s susceptibility to illness. It is also the origin of many food allergies. Food is meant to be fully digested, broken down and filtered through the liver before it ever enters the blood stream. As undigested food particles slip through the gaps into the blood stream, the body’s immune system sees them as foreign invaders and creates immune cells to them. Then next time you eat these food the body remembers them as a potentially threatening invader and creates a reaction to them resulting in a food allergy.

How to Take Further Action

These are possible reactions that can occur over time with a person who is gluten intolerance. Not all people will react in an extreme way, but if you do have intolerance to gluten it is very important that you identify it and avoid all products containing gluten. If you scored 5 or higher on the questionnaire, I recommend you eliminate all gluten-containing foods from your diet for a minimum of two months. At the end of the two months you will notice significant relief (if not elimination) from your symptoms if you are in fact gluten intolerant. If you identify yourself as gluten intolerant you will need to remain gluten-free for the rest of your life to avoid the unwanted and harmful effects of gluten. Gluten-free means avoiding all foods containing gluten, including wheat, rye, spelt, bulgar, semolina, couscous, triticale, and durum flour. Gluten can be hidden, so read labels carefully. Be wary of modified food starch, dextrin, flavorings and extracts, hydrolyzed vegetable protein, imitation seafood, and creamed or thickened products such as soups, stews, and sauces.