SurveyMonkey Powered Online Survey

Thank You For Your Interest In the MyCeliacTeam Beta Program

Thank you for your interest in joining the MyCeliacTeam private beta, a social network for people living with celiac disease. The purpose of this short survey is to learn more about your life with celiac disease. We will be in touch over the coming months for additional feedback as we build out features for MyCeliacTeam.

ALL OF YOUR ANSWERS TO THIS SURVEY WILL BE KEPT COMPLETELY CONFIDENTIAL.

Question Title

* 1. Please tell us about you and where you're from below. (We will not share your information. The information you provide below is completely confidential).

Name:

City/Town:

State:

Email Address:

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* 2. When is your birthday?

Input values (ex. 05/23/1975)

Date

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* 3. What best describes you below?

I am living with celiac disease, but I'm not taking any treatment

I am living with celiac disease, and I'm taking treatment

I care for someone living with celiac disease

Other (please specify what best describes you)