anonymous submission

Patient data form

No name, email, or personally identifying information is collected. The form stores clinical parameters only: age, weight, conditions, drugs, side effects, nutrients, and natural remedies.

Basic patient info

Age (years) *

Gender *

Height

Weight

Race

Medical conditions

Capture the condition the person used the PPI for, any other medical conditions they had alongside it, and any condition they believe the PPI may have triggered.

Condition treated with the PPI *

Suggested values

Other medical conditions present at the same time

Suggested values

Condition believed to be triggered by the PPI

Suggested values

PPI drug exposure

Describe the proton pump inhibitor the person used, including the generic or brand, the dose, how often it was taken, how long it was used, and their overall view of that treatment.

PPI generic name *

PPI brand name

Dose taken

How often it was taken

Length of use *

Overall experience with this PPI

PPI-related side effects

Record side effects the person believes were caused or worsened by the PPI. Choose common values from the list or type a custom side effect if it is not shown.

Did the person report side effects from the PPI?

yesnodont knowunknown

Reported side effects

Suggested values

Nutrient deficiencies linked to PPI use

Record any nutrient deficiencies the person believes were present during or because of PPI use. Choose from the list or add a custom deficiency if needed.

Did the person report a nutrient deficiency related to the PPI?

yesnodont knowunknown

Reported nutrient deficiencies

Suggested values

Natural remedies and supplements

Add natural remedies or supplements the person tried. They can be selected from common options or entered manually if they are not listed.

Natural remedies or supplements that helped

Suggested values

Natural remedies or supplements that did not help

Suggested values