Coeliac Disease Review

If you have been asked the practice to submit a Coeliac Disease Review, please use this form.

For further information on coeliac disease you can contact the Coeliac UK Helpline on 0333 3022 2033 or visit their website at for additional support.

Coeliac Disease Review



Do you currently smoke? *
Have you smoked in the past? *
How many cigarettes did you smoke in a day? *
How many cigarettes do you smoke in a day? *
Would you like help to give up smoking? *

If you would like help or advice to quit smoking, please visit our Wellbeing Centre.

Calculate my BMI

I have my measurements in:
e.g 1.75
e.g 60.6

If your measurements are in Feet and inches/ stones and pounds, please visit NHS UK: BMI Calculator.

Once your BMI has been calculated, please enter this in the box below.

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Do you have any of the following gastrointestinal symptoms: constipation, diarrhoea, nausea or vomiting? *
Do you have mouth ulcers? *
Do you have fatigue / tiredness? *
Do you have any of the following neurological symptoms: headache, persistent change of sensation in your hands or feet, persisting unsteadiness? *

Do you take calcium supplements? *

For details on recommended calcium intake, please visit Calcium Intake and Coeliac Disease.

Do you take any other supplements? *
Are you on long term steroid tablets or have you taken several courses of steroid tablets in the last 12 months? *
Do you have parents or siblings who have been diagnosed with osteoporosis? *
Have you had difficulties in maintaining a strictly gluten free diet? *

Anxiety and Depression

People with coeliac disease may experience anxiety and depression. If you have concerns regarding your mental wellbeing, please book a telephone consultation with a GP for a review by visiting our Consulting Room.

Female Patients

For women with Coeliac disease who are trying to conceive or who are pregnant, it is recommended that the higher dose of 5mg folic acid should be take pre-conception and for the first three months of pregnancy.

This dosage of folic acid is available only via prescription.

Some forms of contraception (combined oral contraceptive pill, progesterone only pill) may be less effective in some patients with coeliac disease. If you have concerns, please book a telephone consultation with a GP by visiting our Consulting Room. It is important not to stop your contraception and to seek medical advice first.