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Celiac Disease Monitoring Chart

Track Your Gluten-Free Journey to Better Health

Gastroenterology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________ Date of Diagnosis: _________________ Gastroenterologist: _________________

Symptom Tracking (Rate 0-5, 0=None, 5=Severe)

Daily Symptoms

Date Abdominal Pain Bloating Fatigue Diarrhea Mood Notes

Laboratory Values

Antibody Tests

  • tTG-IgA Level: _________ Date: _________
  • EMA-IgA Level: _________ Date: _________
  • DGP-IgG Level: _________ Date: _________

Nutritional Status

  • Vitamin D: _________ Date: _________
  • Iron/Ferritin: _________ Date: _________
  • Vitamin B12: _________ Date: _________
  • Folate: _________ Date: _________

Dietary Compliance

Weekly Gluten Exposure Log

  • Intentional exposures: _________
  • Accidental exposures: _________
  • Situations leading to exposure: _________________

Quality of Life Indicators

  • Energy Level (1-10): _________
  • Sleep Quality (1-10): _________
  • Exercise Tolerance (1-10): _________

Follow-up Appointments

Date Provider Key Findings Next Steps

Goals

  1. Short-term: _________________
  2. Long-term: _________________

Notes

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