Eosinophilic Oesophagitis (EoE) is a chronic condition that can have a profound effect not only on the person suffering from this condition, but also their family and carers.  EoE may occur at any age, but this survey is targeted at adult patients with EoE, and to understand better your journey - through first becoming aware of symptoms, then into diagnosis and treatment options.  This survey also asks you to assess the impact of your EoE on your ‘quality of life’ and how it impacts some normal daily activities, for when your symptoms are either under control or NOT under control.  This market research is being conducted by Dr Falk Pharma Australia Pty Ltd, a pharmaceutical company to help provide a better understanding of the impact of this condition on Australian adult patients. This survey should take around 5 minutes to complete. 
BASIC INFORMATION ABOUT YOU (relates to questions 1-3)

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* 1. Your gender:

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* 2. What is your current age?

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* 3. Where do you live?

DIAGNOSIS OF YOUR EoE (relates to questions 4-6)

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* 4. At which age range were you diagnosed?

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* 5. Who first diagnosed your EoE?

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* 6. Was your EoE confirmed by biopsy following endoscopy?

SYMPTOMS (relates to questions 7-11)

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* 7. What symptoms first lead to your EoE diagnosis? (tick all that apply)

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* 8. Are you able to reduce some of your EoE symptoms effectively through any of the following behaviours (tick all that apply):

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* 9. Thinking specifically about a period when your EoE symptoms were NOT well controlled and bothersome to you. How frequently did you visit a doctor because of your EoE?

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* 10. Thinking specifically about a period when your EoE symptoms were well controlled and not bothersome to you. How frequently did you visit a doctor because of your EoE?

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* 11. How often do you routinely have an endoscopy to assess your EoE?

FOOD IMPACTION (relates to questions 12-15)

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* 12. Have you had a ‘food impaction’ event requiring removal, due to your EoE?

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* 13. If yes, how many food impaction events have you had in total?

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* 14. If yes, did some of these food impactions require you to attend a hospital emergency department?

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* 15. If yes, when you were at the emergency department for a food impaction, were you ever transferred to the main hospital for 1 or more days? (i.e. admitted to a ward in the hospital)

TREATMENT (relates to questions 16-21)

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* 16. What treatment for your EoE are you currently receiving?

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* 17. If you are treated with swallowed steroids and is it prepared as a slurry (with Splenda or the equivalent), do you or your carer prepare this or do you use a pharmacy service?

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* 18. Have you changed from one treatment to another as below? (tick all that apply)

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* 19. Why was your treatment changed?

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* 20. Have you needed to have an oesophageal dilation to treat your EoE symptoms?

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* 21. If yes, how often on average?

QUALITY OF LIFE / ACTIVITIES OF DAILY LIVING

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* 22. In what areas has EoE impacted your ‘quality of life’ (tick all that apply)

Under each heading, please tick the box that best describes your health when your EoE symptoms are NOT under control
(relates to Questions 23-27 )

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* 23. MOBILITY

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* 24. SELF-CARE

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* 25. USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities)

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* 26. PAIN / DISCOMFORT

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* 27. ANXIETY / DEPRESSION

Under each heading, please tick the box that best describes your health when your EoE symptoms are under control. 
(relates questions 28-32)

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* 28. MOBILITY

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* 29. SELF-CARE

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* 30. USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities)

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* 31. PAIN / DISCOMFORT

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* 32. ANXIETY / DEPRESSION

DFP2020.39Aug.
Date of preparation: Aug 2020

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