Survey Form

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).

Yes
No

What is the age of the person suffering?

From what age did the person start suffering?

Does the person still suffer from the condition?

Yes
No

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 ...?

 

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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Lactose.co.uk
 
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