Alkem

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VONZAI

A Real-World Evidence Study to Evaluating the Effectiveness, Safety, and Usage of Vonoprazan in Routine Clinical Practice

BASIC DETAILS

Date *

Patient Initials *

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Patient ID (Do not write name here) *

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Eligibility of the subjects

Please tick as applicable

	Yes	No
Male or female subjects within the age group 18 or above
Subject Diagnosed with GERD, peptic ulcer disease, or other approved indications for Vonoprazan.
Prescribed Vonoprazan as part of routine clinical care.
Available clinical records and follow-up data.

Demographic data

Gender*

Male Female

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Subject Initial *

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Date of Birth (DD-MM-YY) *

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Age *

Height (cm) *

Weight (kg) *

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BMI *

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Comorbidities *

Cardiovascular disease Chronic kidney disease Hypertension Obesity Diabetes Heart Failure Others

Diagnosis and treatment details

Primary diagnosis *

Other Relevant Diagnoses *

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Date of First Prescription *

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Indication for Vonoprazan *

Initial Dose & frequency *

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Duration of treatment *

Start date

End date

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Current Dose *

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Reason for Dose Adjustment (If dose adjusted)

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Baseline symptoms (Before use of Vonoprazan)

Heartburn Severity *

Mild Moderate Severe

Acid Regurgitation *

Yes No

Other Symptoms

Post treatment symptoms

Heartburn Severity *

Mild Moderate Severe

Acid Regurgitation *

Yes No

Other Symptoms

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Follow up period *

Start date

End date

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Patient-Reported Outcomes

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Quality of life assessment (If applicable)

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Instrument Used

Baseline Score

Follow-Up Score

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Symptom Relief

Heartburn Relief *

Improved No change Worsened

Acid Regurgitation Relief *

Improved No change Worsened

Other Symptoms Relief

Overall Satisfaction with Treatment

Rating *

Very Satisfied Satisfied Neutral

Comments if any (Additional patient comments)

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