(H Pylori) Helicobacter Pylori Survey/Questionnaire

General Water-Survey/Questionnaire
Incarcerated Individuals Information

First NameLast Name
TDCJ#
How long has your loved been incarcerated?
What unit are you currently housed in??
Are you married? or have a significant other?

YesNo
If so, for how long?
How many units have they been to?
What are the names of them?
RELATED MEDICAL CONCERNS
Do you have a HIPAA authorization on file?

YesNo
Have you been denied medical treatment?

YesNo
Have you sought medical treatment?

YesNo
CHECK THE FOLLOWING SYMPTOMS YOU HAVE EXPERIENCED?

An ache or burning pain in your stomach (abdomen)Stomach pain that may be worse when your stomach is empty.Loss of appetiteNauseaFrequent burpingUnintentional weight lossBloating or swellingOther
Do you have any ulcers?

YesNo
If yes, when were you diagnosed with an ulcer?
Have you ever suffered from any gastrointestinal issues?

YesNo
If so for how long?
Have you ever been tested for H-Pylori (Helicobacter Pylori) ?

YesNo
If so, when? and where?
If so, did they give you your results?

YesNo
Did you test positive?

YesNo
If tested positive, were you prescribed medical treatment?

YesNo
If you obtained medical treatment, did you request to be re-tested?

YesNo
Were you re-tested?

YesNo
Grievances
Have you filed a grievance (s) regarding your health or lack of medical treatment?

YesNo
Step I Grievance filed (1)

YesNo
Step II Grievance filed (2)

YesNo
If yes what are the results from Step I or II Step Grievance?
Do you have an attorney?

YesNo
If not, would you be interested in participating in a class action lawsuit?

YesNo
If you would like to share any additional information, or have any relevant documentation and/or, have anything you feel may be helpful, or know of someone who would like a survey please have them send us a self-addressed stamped envelope to this address below:

Texas Prisons Alliance
P.O. Box 1563
Pearland, TX 77588

Email: texasprisonsalliance@gmail.com
Should be Empty:

General Water-Survey/Questionnaire

RELATED MEDICAL CONCERNS

Grievances