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Name:
Phone:
() -
E-mail:
State:
Which PPI (acid reflux, ulcer) drugs did you take?
Prilosec
Prevacid
Protonix
Nexium
Acipex
Other
For how many years were you taking the PPI (acid reflux, ulcer) drugs?
Please describe your injuries and treatment:
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PERSONAL INFORMATION
First Name:
Last Name:
E-mail Address:
Address:
City:
State:
Zipcode:
Phone: -

INCIDENT INFORMATION
Which PPI (acid reflux, ulcer) drugs did you take? Acipex
Nexium
Other
Prilosec
Prevacid
Protonix
For how many years were you taking the PPI
(acid reflux, ulcer) drugs?
Date you started to take PPI drugs
Date you stopped taking PPI drugs
Did you suffer a fracture during or soon after taking
this medication?
Yes
No
Have you developed Osteoporosis? Yes
No
Please describe your injuries and treatment:
Please provide any other questions or comments:
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