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CSI Shop Voucher

A great gift idea – a voucher to spend on any* CSI service or in our shop stocked full of gluten free goodies

* excludes membership

Gender *

Male

Female

Date of Birth *

e.g 01/01/1990

Is membership for someone under 18? *

Guardian Name

If member is under 18 please add parent/guardian name here. Members under 18 years of age must have the consent of their parent or guardian.

Year of Diagnosis *

Just the year e.g., 2021

Diagnosis *

Please select your diagnosis

Symptoms *

Please select your symptoms

Anaemia

Stomach Pain

Failure to Thrive

Indigestion

Depression

Vomiting

Fatigue

Constipation

Mouth Ulcers

Moodiness

Rash

IBS

Diarrhoea

Weight Loss

Bloating

Bone Pain

Flatulence

No Symptoms

Method of Diagnosis *

Other Autoimmune Conditions: *

Diabetes – Type 1

Hashimoto Disease

Grave’s Disease

Autoimmune Hepatitis

Rheumatoid Arthritis

Addison’s Disease

Primary Biliary Cholangitis

Fibromyalgia

Psoriasis

IDC

IgA Nephropathy

Crohn’s Disease

Psoriatic Arthritis

Sarcoidosis

Ankylosing spondylitis

Ulcerative proctitis

Polymyalgia rheumatica

Microscopic colitis

Polymyalgia

Immune thrombocytopenic purpura with myelodysplastic syndrome

Ulcerative colitis

Lupus

Lymphocytic colitis

Autoimmune pancreatitis

Autoimmune progesterone dermatitis

Systemic sclerosis

No Other Conditions

Sjogren’s Syndrome

Other Conditions (non-autoimmune) *

Osteoporosis

Anaemia

Thyroid Disease

Infertility

Multiple Miscarriage

Migraines

Insestinal Cancers

No other conditions

Have any of your family members been diagnosed with/tested for Coeliac Disease? *

If you answered yes to the above, how many that you know of?

If you answered yes to the family members question, how are they related to you?

Sister

Brother

Mother

Father

Aunt – mother’s sister

Uncle – mother’s brother

Aunt – father’s sister

Uncle – father’s brother

1st Cousin – female mother’s side

1st Cousin – male mother’s side

1st Cousin – female father’s side

1st Cousin – male mother’s side

How did you hear about the Society? *

Dietitian Referral

My GP

Consultant Gastroenterologist

Practice Nurse

Local Pharmacy

Radio Interview

Radio Ad

Social Media

Newspaper article

Internet search

A current member

A past member

CSI Shop Voucher quantity

CSI Shop Voucher

Contact Us

01 872 1471
info@coeliac.ie
Dolcan House, 78/80 Tower Road, Clondalkin, Dublin 22 D22 N6F6

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