Carrageenan Questionnaire

Name

Age

Gender

City, State

Email

We will never share, rent or sell your personal information or email address. Please provide your email address for follow-up and verification purposes. We will not be able to count your questionnaire if you do not enter your email address. If you do not have an email address, please provide a phone number or physical address.

1. Please check which condition applies to you after you eliminated carrageenan from your diet (check all that apply):

a. Gastrointestinal symptoms completely disappeared
b. Gastrointestinal symptoms improved
c. No change in gastrointestinal symptoms
d. Gastrointestinal symptoms became worse.

If you answered a. or b., please answer the additional questions below.

2. Please describe the gastrointestinal symptoms you experienced before eliminating carrageenan from your diet. (check all that apply)

Additional Symptoms

3. Did you discuss these symptoms with your doctor? If yes, what was your doctor’s diagnosis?

4. How long were you on a carrageenan-free diet before you noticed the change?

1-3 days
4-7 days
1-2 weeks
2 weeks or longer

5. Before your symptoms improved, how long have you suffered from gastrointestinal discomfort?

Less than a year
1-3 years
3-10 years
more than 10 years

6. How did you find out that eliminating carrageenan from your diet might lead to improvements in your gastrointestinal health?

On a scale of 1-5, with 1 being “terrible” and 5 being “excellent”, how would you rate the following:

7. Your gastrointestinal health before eliminating carrageenan from your diet:

8. Your gastrointestinal health after eliminating carrageenan from your diet:

9. Your general health before eliminating carrageenan from your diet:

10. Your general health after eliminating carrageenan from your diet:

11. Your ability to enjoy activities away from home before eliminating carrageenan from your diet:

12. Your ability to enjoy activities away from home after eliminating carrageenan from your diet:

13. Your ability to work before eliminating carrageenan from your diet:

14. Your ability to work after eliminating carrageenan from your diet:

15. Your ability to exercise before eliminating carrageenan from your diet:

16. Your ability to exercise after eliminating carrageenan from your diet:

17. Did you notice any other changes after eliminating carrageenan from your diet? If yes, please describe.

18. How successful have you been at eliminating carrageenan from your diet?

Not successful (I have made no attempt to change my consumption of carrageenan)
Somewhat successful (I have reduced my consumption of carrageenan, but I do continue to knowingly eat some foods with carrageenan on a consistent basis)
Fairly successful (I have eliminated most foods with carrageenan, but occasionally consume foods with carrageenan)
Very successful (I have eliminated all foods with carrageenan at home, but may consume carrageenan unknowingly when occasionally eating out or drinking beer)
Completely successful (I have eliminated carrageenan completely, including not eating any foods when eating out unless I have been able to verify they are free of carrageenan, and eliminating beer consumption)

19. Do you plan to continue eliminating carrageenan from your diet?