We are conducting a survey to assess who is likely to suffer from these conditions. Please fill in a separate form for every member of the family who suffers from any of these conditions.
You do not need to include names, addresses or emails because we only need statistical values. Make sure to fill all sections for us to be able to produce significant results.
Do you or a member of the family suffer from Lactose Intolerance or Milk Allergy?
Yes No
If yes from what?
Lactose intolerance Milk allergy and also food allergy?
Do you or the member who suffers had older relatives suffering from the condition/s (eg. Grandfather).
What is the age of the person suffering?
From what age did the person start suffering?
Does the person still suffer from the condition?
How much is the daily life of the sufferer affected by these conditions?
1 -- 2 -- 3 -- 4 -- 5 -- 6 -- 7 -- 8 -- 9 -- 10 ( 1 = unaffected ->10 = most affected)
Do you or the sufferer try to control it by ...?
avoiding some dairy products avoiding all dairy products avoiding drinking milk avoiding milk and chocolates do nothing and live with it take medicine tablets or other medicine
Is the suffer
Male Female
What is the ethnicity of the person suffering?
If mixed how would you describe yourself? (E.g. c+d)?
Where are is the person with the condition from?
If you wish to add some comments please type in the space provided.
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