PEER SUPPORT REQUEST FORM

About You

Tell us more about yourself and how we can get in touch.

First Name*

Last Name

Preferred Pronouns*

she/her
he/him
they/them
she/they
he/they
other

Age Range*

18-24
25-34
35-44
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55-64
65-74
75-84
85+

Street Address*

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Preferred Contact Method*

Email
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🇵🇰 Pakistan (‫پاکستان‬‎) +92
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🇰🇳 Saint Kitts and Nevis +1869
🇱🇨 Saint Lucia +1758
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🇼🇸 Samoa +685
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🇸🇦 Saudi Arabia (‫المملكة العربية السعودية‬‎) +966
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🇸🇰 Slovakia (Slovensko) +421
🇸🇮 Slovenia (Slovenija) +386
🇸🇧 Solomon Islands +677
🇸🇴 Somalia (Soomaaliya) +252
🇿🇦 South Africa +27
🇰🇷 South Korea (대한민국) +82
🇸🇸 South Sudan (‫جنوب السودان‬‎) +211
🇪🇸 Spain (España) +34
🇱🇰 Sri Lanka (ශ්‍රී ලංකාව) +94
🇸🇩 Sudan (‫السودان‬‎) +249
🇸🇷 Suriname +597
🇸🇿 Swaziland +268
🇸🇪 Sweden (Sverige) +46
🇨🇭 Switzerland (Schweiz) +41
🇸🇾 Syria (‫سوريا‬‎) +963
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🇹🇿 Tanzania +255
🇹🇭 Thailand (ไทย) +66
🇹🇱 Timor-Leste +670
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🇹🇰 Tokelau +690
🇹🇴 Tonga +676
🇹🇹 Trinidad and Tobago +1868
🇹🇳 Tunisia (‫تونس‬‎) +216
🇹🇷 Turkey (Türkiye) +90
🇹🇲 Turkmenistan +993
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🇹🇻 Tuvalu +688
🇻🇮 U.S. Virgin Islands +1340
🇺🇬 Uganda +256
🇺🇦 Ukraine (Україна) +380
🇦🇪 United Arab Emirates (‫الإمارات العربية المتحدة‬‎) +971
🇬🇧 United Kingdom +44
🇺🇸 United States +1
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🇺🇿 Uzbekistan (Oʻzbekiston) +998
🇻🇺 Vanuatu +678
🇻🇦 Vatican City (Città del Vaticano) +39
🇻🇪 Venezuela +58
🇻🇳 Vietnam (Việt Nam) +84
🇼🇫 Wallis and Futuna +681
🇾🇪 Yemen (‫اليمن‬‎) +967
🇿🇲 Zambia +260
🇿🇼 Zimbabwe +263

Best Contact Times*

When is the best time for someone to contact you (in your own time zone)?

Morning (8am-12pm)

Afternoon (12pm-5pm)

Evening (5pm-8pm)

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PEER SUPPORT REQUEST FORM

Your C. diff Experience

Please answer the following questions to the best of your ability. If you're making a request because someone you care for has C. diff, answer the questions as they relate to your loved one.

Infection Status*

I think I have C. diff but I'm not sure
I'm on my first occurrence of C. diff
I'm experiencing a C. diff recurrence
I'm technically cured but I'm still struggling to feel better

When were you first diagnosed with a C. diff infection?*

If you haven't had a confirmed diagnosis, when did you begin to feel like you might have C. diff?

Source of Infection*

To the best of your knowledge, where did you likely contract C. diff?

Healthcare-associated
Community-associated
I'm not sure

In your opinion, how much has C. diff negatively impacted your day-to-day life?*

Not at all
A little
A considerable amount
Greatly

Specific Topics

What are you most concerned about?

Mental health

Diet and nutrition

Other lifestyle aspects

Accessing specific healthcare providers or services

Insurance coverage

Enrolling in clinical trials

Cleaning and infection prevention

Getting diagnosed

Additional Information

Is there anything else you'd like us to know about you?

Which of the following treatment options, if any, have you received for your C. diff infection?*

Please check all that apply.

Vancocin/vancomycin

Dificid/fidaxomicin

Flagyl/metronidazole

Rebyota

Vowst

Zinplava/bezlotoxumab

FMT

IVIG

Clinical Trial

Other

Peggy Lillis Foundation will use your contact information to send you updates about C. diff and the foundation. You may unsubscribe from these communications at any time. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, please review our Privacy Policy.

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