Alkem

Rabeprazole

A Multicenter, Prospective, Observational, `Real-World Evidence Study to Assess the Effectiveness and Safety of Rabeprazole and Rabeprazole-Domperidone Combination in the patients with acid peptic diseases.

Subject Code. *

Patient Initials *

Investigator *

Centre *

ASSESSMENT 1 - BASELINE VISIT

Date of assessment *

Demographic Details

Age (in Years) *

Gender *

Male Female

Symptoms *

Medical and Surgical history (If any)

Diagnosis *

Non erosive reflux disease (NERD) Gastro-esophageal reflux disease (GERD) GERD with Nausea and Vomiting GERD with associated symptoms Peptic Ulcer Disease (PUD) PUD with complications (Barret's Esophagus, GI bleed etc. Others

Treatment Given *

Rabeprazole Rabeprazole-Domperidone

Dose *

Frequency *

Duration*

A. GERD questionnaire *

Question
	Frequency score (points) for symptom
	0 day	1 day	2-3 days	4-7 days
	1. How often did you have a burning feeling behind your breastbone (heartburn)?	0	1	2	3
2. How often did you have stomach contents (liquid or food) moving upwards to your throat or mouth (regurgitation)?	0	1	2	3
3. How often did you have a pain in the centre of the upper stomach?	3	2	1	0
4. How often did you have nausea?	3	2	1	0
5. How often did you have difficulty getting a good night's sleep because of your heartburn and/or regurgitation?	0	1	2	3
6. How often did you take additional medication for your heartburn and/or regurgitation, other than what the physician told you to take? (such as Tums, Rolaids, Maalox?)	0	1	2	3
Total score

B. Patient perception of symptoms on VAS scale (0 being least symptoms and 10 being most symptoms) *

@if ($assessment_type == 1 || is_null($assessment_type))

@endif

ASSESSMENT 2 - Follow up/2^nd Visit

Date of assessment *

Duration of treatment taken (Days) *

A. GERD questionnaire *

Question
	Frequency score (points) for symptom
	0 day	1 day	2-3 days	4-7 days
	1. How often did you have a burning feeling behind your breastbone (heartburn)?	0	1	2	3
2. How often did you have stomach contents (liquid or food) moving upwards to your throat or mouth (regurgitation)?	0	1	2	3
3. How often did you have a pain in the centre of the upper stomach?	3	2	1	0
4. How often did you have nausea?	3	2	1	0
5. How often did you have difficulty getting a good night's sleep because of your heartburn and/or regurgitation?	0	1	2	3
6. How often did you take additional medication for your heartburn and/or regurgitation, other than what the physician told you to take? (such as Tums, Rolaids, Maalox?)	0	1	2	3
Total score

B. Patient perception of symptomatic improvement on VAS scale (0 being least symptoms and 10 being most symptoms) *

Rabeprazole

ASSESSMENT 1 - BASELINE VISIT

Demographic Details

ASSESSMENT 2 - Follow up/2nd Visit

ASSESSMENT 2 - Follow up/2^nd Visit