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Living with Celiac in Long Term Care Facilities
1.
Who are you filling this survey for:
Family member
Friend
Other (please specify)
2.
Is the person you are filling the survey for currently in a long-term care facility?
Yes
No
Planning to move into one
Other (please specify)
3.
How old was the resident when diagnosed with Celiac Disease?
<18
18-35
35-60
>60
Don’t know
4.
How long has the resident been in the current facility?
<1 year
1-3 years
3-5 years
>5 years
Don’t know
5.
Did you find it difficult finding a placement in a facility specifically due to celiac disease?
Yes
No
6.
Other than a gluten-free diet, what other types of diet is the resident following?
Just celiac (gluten free)
Diabetic
Kidney disease (Renal)
High protein/ high energy
Don't know
Other (please specify)
7.
What meal texture your family member is receiving
Regular
Minced
Pureed
Don’t know
8.
Did you or a family member discuss at length the requirements for the GF diet with staff?
Yes
No
9.
If you answered
yes
to the previous question, who did you discuss it with? Check all that apply.
No one discussed the requirements for the GF diet with staff
Food service Manager
Dietitian
Social worker
Physician at the LTC home
Other (please specify)
10.
How does your family member or friend access food? Check all that apply.
Delivered to room
Dining Room Buffet
Dining Room – Service at table
Food from family or friends
Other (please specify)
11.
Does your family member require assistance with feeding?
No, able to self-feed
Yes, some assistance
Yes, substantial assistance
Don’t know
12.
What types of accommodations are made in the facility to provide gluten-free meals to the resident:
13.
How would you estimate the level of knowledge on gluten-free diet and cross-contamination of the
food service staff
in the facility?
knowledgeable
Somewhat knowledgeable
Limited knowledge
Don't know
14.
How would you estimate the level of knowledge on gluten-free diet and cross-contamination of the
staff helping in feeding
the resident in the facility?
Very knowledgeable
Somewhat knowledgeable
Limited knowledge
Don't know
15.
What your estimation is based on: Check all that apply.
Interaction with staff
Feedback from other residents or family members
Experiencing episodes of CD symptoms
Other (please specify)
16.
Rate how confident you are that the resident is receiving uncontaminated food?
Very confident
Somewhat confident
Neutral
Somewhat unconfident
Very unconfident
17.
How would you rate the quality of the diet (nutrition, variety, quality)?
Excellent
Good
Neutral
Bad
Very bad
18.
Has the resident had any illnesses directly related to cross-contamination of their celiac diet in the LTC facility?
Never
1-3 times
> 5 times
Don't know
19.
If you answered yes to illness related to cross-contamination question, was the resident ever admitted to hospital for treatment?
Yes
No
Don't know
20.
If you are filling this survey for a family member or friend, is the resident aware of their CD diagnosis (mentally capable):
Yes
No
Somewhat
Other (please specify)
21.
What Province is the resident located?
AB
BC
MB
NB
NL
NS
ON
PE
QC
SK
NT
NU
YT
22.
Do you have any other comments, questions, or concerns?
23.
Would you like to share your story with us?
Name or initials:
e-mail address:
Phone number:
Your story:
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