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Eosinophilic Esophagitis (EoE) Survey for Patients/Caregivers

APFED has partnered with Vindico CME to gather feedback to inform clinician education.
If multiple family members have EoE, answer based on the most severe or symptomatic case.

1.Which healthcare professionals have you/the patient visited for issues or concerns related to eosinophilic esophagitis (EoE)? Check all that apply.(Required.)
2.When were you/the patient diagnosed with EoE?(Required.)
3.From when symptoms of EoE first appeared, how long did it take to get an EoE diagnosis?(Required.)
4.Have you/the patient also been diagnosed by a healthcare provider with any of the following allergic conditions? Check all that apply.(Required.)
5.How often do you/the patient typically need to see a healthcare professional for your EoE?
Please include any EoE-related visits to a specialist, primary care, urgent care and/or emergency department.(Required.)
6.Have you self-administered over-the-counter medications for your symptoms? Please check ALL that apply.(Required.)
Currently using this treatment
Previously used this treatment
Never used this treatment
I'm not sure
Over-the-counter antacids (Examples: calcium carbonate (Tums, Alka-Seltzer), aluminum hydroxide, bismuth subsalicylate (Pepto-Bismol), magnesium hydroxide, and simethicone (Mylanta))
Over-the-counter H2 blockers (Examples: cimetidine (Tagamet HB), famotidine (Pepcid), ranitidine (Zantac 360))
7.What treatments have you used to manage your/the patient’s EoE? Please check ALL that apply.(Required.)
Currently using this treatment
Previously used this treatment
Never used this treatment
I'm not sure
Proton pump inhibitors (Examples: esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec))
Dupilumab (Dupixent)
Budesonide oral suspension (Eohilia)
Off-label swallowed (topical) corticosteroids (Examples: budesonide (Pulmicort), fluticasone (Flovent), etc.)
Food elimination diet
Elemental diet without a feeding tube
Elemental diet with a feeding tube
Esophageal dilation procedure
8.What do you consider to be the most important factor(s) when deciding which treatment to choose? (Choose up to 2.)(Required.)
9.What do you consider to be the most important factor(s) for deciding whether your/the patient’s treatment is successful? (Choose up to 2.)(Required.)
10.If you/the patient discontinued or changed EoE treatments in the past, what were the reasons? Check all that apply.(Required.)
N/A
didn't use
Didn't work well enough
Side effects
Inconvenience
Cost
Better option became available
Condition improved / no longer needed
Other reason
Proton pump inhibitors
Budesonide oral suspension (Eohilia)
Other swallowed corticosteroids (off-label)
Dupilumab (Dupixent)
11.Please rate how much you agree with these statements about your/the patient’s EoE diagnosis and treatment (5 = strongly agree, 1 = strongly disagree):(Required.)
5
Strongly agree
4
Somewhat agree
3
Neutral
2
Somewhat disagree
1
Strongly disagree
N/A
I have a clear understanding of my/the patient’s treatment goals and plan.
I am happy/satisfied with my/their treatment plan.
Symptoms are well-controlled on treatment.
Symptoms interfere with daily life activities.
Symptoms affect school, work, or sleep.
I/the patient find dietary management to be challenging or difficult.
Healthcare team members communicate well regarding my/the patient’s EoE care.
Healthcare team members collaborate well with each other to manage my/the patient’s condition(s).
I am familiar with Eohilia (ie, budesonide oral suspension) as a treatment option for EoE.
I am familiar with Dupixent (ie, dupilumab, a biologic medication) as a treatment option for EoE.
I/the patient am willing to try new treatments.
12.Age of the person with EoE (in years): ___________(Required.)
13.What is the person with EoE’s gender?(Required.)
14.What is the person with EoE’s race or ethnicity? Check all that apply.(Required.)
15.If you would like to be entered into a raffle for a chance to win one of five $100 Amazon gift cards, please provide your email. Participants that fully complete the survey will be eligible for the raffle.