(H Pylori) Helicobacter Pylori Survey/Questionnaire

  • General Water-Survey/Questionnaire

  • Are you married? or have a significant other?

  • RELATED MEDICAL CONCERNS

  • Do you have a HIPAA authorization on file?
  • Have you been denied medical treatment?
  • Have you sought medical treatment?
  • CHECK THE FOLLOWING SYMPTOMS YOU HAVE EXPERIENCED?
  • Do you have any ulcers?
  • Have you ever suffered from any gastrointestinal issues?
  • Have you ever been tested for H-Pylori (Helicobacter Pylori) ?
  • If so, did they give you your results?
  • Did you test positive?
  • If tested positive, were you prescribed medical treatment?
  • If you obtained medical treatment, did you request to be re-tested?
  • Were you re-tested?

  • Grievances

  • Have you filed a grievance (s) regarding your health or lack of medical treatment?
  • Step I Grievance filed (1)
  • Step II Grievance filed (2)
  • Do you have an attorney?
  • If not, would you be interested in participating in a class action lawsuit?

  • 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

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