CDF Patient Advocate Registration Question Title * 1. Please enter your contact information. First Name * Last Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Country Email Address * Phone Number * Question Title * 2. What is your gender? Female Male Question Title * 3. What is your date of birth? Birth Date Date Question Title * 4. Have you been diagnosed with celiac disease or gluten sensitivity by a licensed physician? Yes No Question Title * 5. Are you a caregiver for someone diagnosed with celiac disease or gluten sensitivity by a licensed physician? Yes No Question Title * 6. Please provide the birthdate for each patient you care for. Birthdate Date Birthdate Date Birthdate Date Birthdate Date Question Title * 7. What was your age of diagnosis? Question Title * 8. Please provide the age of diagnosis for each patient you care for. Age Age Age Age Question Title * 9. Please provide any additional information you would like us to know. Done
