Questionnaire on lactose intolerance

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Q u e s t i o n s

1) Type of intolerance ?
(several answers can be checked)

I think I am lactose intolerant
I have been diagnosed to have a lactose intolerance
I think I am gluten intolerant / celiac disease
I have been diagnosed to have a gluten intolerance / celiac disease
I think I am milk intolerant
I have been diagnosed to have a milk intolerance
I think I have Crohn's disease or colitis disease
I have been diagnosed to have Crohn's disease or colitis disease
I think I have an irritable bowel syndrome
I have been diagnosed to have an irritable bowel syndrome
I don't know if I have a lactose or a milk intolerance
I don't know if I have a lactose or other intolerance

2) Type of symptoms ? (if they are present)
(several answers can be checked)
I have diarrhea
I have pain - cramps
I have bloating
I have gas
I have nausea

3) Since when are the symptoms present ?


4) Impact of the symptoms : ?


5) Impact of the diet if you have adopted one :

6) If you have tried a diet where does it come from ?


7) Do you take synthetic lactase (ex: Lactaid - Lactease - Dairy Relief) ?


8) Impact of synthetic lactase if you have tried it : ?

 

9) Do you think there is lactose in the following items ?
    (choose between Yes / No or ??? (I don't know))
  Yes No ???
    - Milk  
    - Yogourt  
    - Fermented milk with thermic process  
    - Cheese  
    - Pork meat  
    - Prepared meals sold in shops
    (ex : pizza, soup, maccaroni with cheese)  
    - Croissant  
    - Ice cream  
    - Eggs  
    - Mayonnaise sold in shops,
    dressings

10) Family situation :


11) Work :


12) Physical activity :


13) Which following meals do you normally take during the week ? :
(several answers can be checked)
morning : breakfast
lunch / diner (hot meal) - sandwiches / snack
evening : super (diner) (sandwiches) / snack - hot meal
one break between meals
two breaks between meals

14) Which of the following meals do you normally take during the week-end ? :
(several answers can be checked)
morning : breakfast
lunch / diner (hot meal) - sandwiches / snack
evening : super (diner) (sandwiches) / snack - hot meal
one break between meals
two breaks between meals

15) Do you often go to the restaurant ? :


16) What kind of food do you normaly buy ? :
(several answers can be checked)
ready to cook food
frozen food (natural or prepared)
fresh food
tined (canned) food (natural or prepared)
others (Please precise)
 
  17) Do you eat the followings ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - white bread
    - brown bread
    - Wholebran bread
    - Milk bread
    - bread with sugar
    - Croissants
    - Pastry
    - Dainish pastries
    - Biscuits
 
  18) Do you eat the followings ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Rice
    - Pastas
    - Potatoes
    - Mashed potatoes / croquettes
    - Other potatoes preparations
 
19) Do you eat vegetables : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Naturaly cooked
    - Cooked in sauce
    - Raw
    - Fried
 
  20) Do you eat meat / poultry / fish / eggs / same : ?
  Yes No
    - Meat
    - Poultry
    - Fish
    - Eggs
    - Same
    - Others (Please precise)
 
21) Do you eat the following meat preparations : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Hamburger
    - Raw meat like hamburger (natural)
    - Raw meat like hamburger (prepared)
    - Blood pudding
    - Corned beef
    - Others (Please precise)
 
22) Do you eat pork meat : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Fat pork meat (ex: pâté, salami,
    saucisson, ...)
    - Lean pork meat (ex: ham, saxe
     filet, turkey dinde, ...)
    - I sometimes eat fat pork meat
    and I sometimes eat lean pork meat
    - Others (Please precise)
 
23) Do you eat dairy products : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Milk
    - Yogourt
    - Milk or yogourt fermented with thermic
     treatment
    - Dessert cream like pudding
    - Whipped Cream
    - Ice cream
    - Others (Please precise)
 
  24) Do you use substitutes to dairy products ?
  Yes No
    - Lactose POOR milk
    - Soya milk
    - Almond milk
    - Rice milk
    - Soya yougourt
    - Soya milk for cooking
    - Ice cream made with soya milk
    - Sorbets
    - Dessert made with soya
    - Others (Please precise)
 
25) Do you eat the following cheese : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Gouda
    - Gruyère
    - Camembert
    - Brie
    - Goat
    - White cheese
    - Melted cheese
    - Others (Please precise)
 
26) Do you tolerate the following cheese?
    (choose between Yes / No or ??? (I don't know))
  Yes No ???
    - Cottage cheese
    - Cheddar
    - Swiss
    - Ricotta
    - Lactose free cheese
    - Tofu
    - Others (Please precise)
 
27) Do you use the following fat products : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Margarine
    - Minarine - Nostrossls
    - Butter
    - Light butter
    - Others (Please precise)
 
28) Do you use dressings or sauces with your salades : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Mayonnaise, sauce or industrial vinaigrette
    - Mayonnaise, sauce or vinaigrette home
     made
    - Sauce dressing or light industrial
    - Sauce dressing or light home
     made
    - Lactose free mix home made
    - Others (Please precise)
 
29) Do you eat the following : ?
  Yes (1-3X/week) Yes (+ than 3X/week) No
    - Chips
    - Peanuts
    - Aperitif biscuits
    - Chocolate
    - Snacks
    - Chocolate sweets
    - Chocolate products
    - Sweets
    - Others (Please precise)

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