Share Your Story - Peggy Lillis Foundation

Demographic Information

This section asks for info about the person who had C. diff. If you’re writing on behalf of someone else, please indicate that below.

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Name *

The name of the person who had C. diff

Submitted by

Your name (If it's your story, enter "same.")

Email *

(We will not share it.)

Cell Phone Number *

(No hyphens. We will not share it)

Age

Age display text (Optional)

Gender

Length

State of Residence (Location)

If you live outside the United States, please choose International.

C. Diff Story

Use this section to provide a brief narrative of your story and related information about it.

*

Write or copy + paste your story into this field.

Source of Infection

Hospital Acquired
Community Acquired
Long-term Care Facility-acquired
Other

Source of Infection Other

Risk Factors

Which, if any, of the following factors may have made you vulnerable to a C. diff infection

Current or recent antibiotic use (within 6 months)
Protopump Inhibitor use (antacids like Prilosec or Prevacid)
Recent stay in a healthcare facility or long-term care facility
Recent serious illness or medical procedure
Aged 65 or greater
None of the above
Other

Risk Factors Other

Treatment

Which, if any, of the following factors may have made you vulnerable to a C. diff infection

Treatment Other

Number of Recurrences

The number of recurrences, if any.

Were you aware of C. diﬀ before being diagnosed?

Please choose answer closest to your experience.

I had never heard of it.
I had heard the word but didn’t know much.
I was familiar with C. diﬀ but didn’t think I was at risk.
I was very knowledgable about C. diﬀ.
Other

Other

In terms of non-medical support, what would have made the biggest diﬀerence in your C. diﬀ experience?

Other

RESTRICTION ON USE

Please indicate any restrictions you’d like PLF to observe when sharing your story. (optional)

Restrictions

Do not publish my last name
Do not use the story in fundraising materials
Do not share my story with the press
Other

Restrictions Other

HOW YOU CAN HELP

PLF is working diligently to build a nationwide C. diff awareness movement and advocate for change. We would love to have you join us. Please indicate below how you’d like to be involved and someone from the foundation will contact you.

I want to help PLF build a nationwide C. diﬀ awareness movement by...

Other

ADVOCATES COUNCIL MEMBER NOTICE

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