12 - 24 Months

2 - 5 Years

6 - 11 Years

12 - 17 Years

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Prevacid® SoluTab™ (lansoprazole)

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Doctor Discussion Guide

GERD Diary

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My Endoscopy Story

pH Probe

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My Child's Health Notebook

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Register and receive your FREE copy of My Child's Health Notebook.

This notebook gives you a place to

• Record your child's symptoms, including those that may be signs of gastroesophageal reflux disease (GERD).
• Chart your child's growth.
• Keep track of your child's immunization history.

* Indicates required field.
Guardian's First Name *
Guardian's Last Name *
Email Address *
Home Telephone	(  )  -
Address Line 1 *
Address Line 2
City *
State *	(Choose One) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip *

Please send me valuable offers and other information from Prevacid in the future.

Please tell us a little about the child or children you are requesting information for:
(You must answer the questions below for at least one child. You may enter information for up to three children.)

CHILD ONE

	Date of Birth	Gender	Diagnosed with Acid Reflux or GERD?	Currently taking Prevacid?
Child 1 *	Month January February March April May June July August September October November December   Year 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006	... Male Female	... Acid Reflux GERD No	... Yes No

Please answer these additional, optional questions about your child/children so that we may better serve you in the future.

1	Check off each symptom your child had before any treatment. (check all that apply) Nausea Vomiting/Regurgitation Wheezing Stomach pain Coughing Hoarseness Refusal to eat/Poor weight gain Heartburn
2	How long has your child had these symptoms? Less than 3 months 3–6 months 6 months–1 year Over 1 year
3	Have you spoken to your child's healthcare provider about these symptoms? Yes No
4	What medication is your child currently taking to treat these symptoms? Prescription only Over-the-counter product A combination of prescription and over-the-counter product None
5	How satisfied are you with your child's current treatment? Very satisfied Somewhat satisfied Not very satisfied Not satisfied at all

CHILD TWO

	Date of Birth	Gender	Diagnosed with Acid Reflux or GERD?	Currently taking Prevacid?
Child 2	Month January February March April May June July August September October November December   Year 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006	... Male Female	... Acid Reflux GERD No	... Yes No

Please answer these additional, optional questions about your child/children so that we may better serve you in the future.

1	Check off each symptom your child had before any treatment. (check all that apply) Nausea Vomiting/Regurgitation Wheezing Stomach pain Coughing Hoarseness Refusal to eat/Poor weight gain Heartburn
2	How long has your child had these symptoms? Less than 3 months 3–6 months 6 months–1 year Over 1 year
3	Have you spoken to your child's healthcare provider about these symptoms? Yes No
4	What medication is your child currently taking to treat these symptoms? Prescription only Over-the-counter product A combination of prescription and over-the-counter product None
5	How satisfied are you with your child's current treatment? Very satisfied Somewhat satisfied Not very satisfied Not satisfied at all

CHILD THREE

	Date of Birth	Gender	Diagnosed with Acid Reflux or GERD?	Currently taking Prevacid?
Child 3	Month January February March April May June July August September October November December   Year 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006	... Male Female	... Acid Reflux GERD No	... Yes No

Please answer these additional, optional questions about your child/children so that we may better serve you in the future.

1	Check off each symptom your child had before any treatment. (check all that apply) Nausea Vomiting/Regurgitation Wheezing Stomach pain Coughing Hoarseness Refusal to eat/Poor weight gain Heartburn
2	How long has your child had these symptoms? Less than 3 months 3–6 months 6 months–1 year Over 1 year
3	Have you spoken to your child's healthcare provider about these symptoms? Yes No
4	What medication is your child currently taking to treat these symptoms? Prescription only Over-the-counter product A combination of prescription and over-the-counter product None
5	How satisfied are you with your child's current treatment? Very satisfied Somewhat satisfied Not very satisfied Not satisfied at all

Please indicate here if you have more than 3 children suffering from GERD symptoms. If so, please complete information for the children who display the greatest number of symptoms.

IMPORTANT SAFETY AND OTHER INFORMATION:
Prescription Prevacid is approved for GERD in children aged 1–17 years. Individual results may vary. Prevacid Capsules and Prevacid® SoluTab™ (lansoprazole) Orally Disintegrating Tablets may not be right for everyone. Prevacid has a low occurrence of side effects in adults and children including diarrhea, abdominal pain, nausea, dizziness, constipation, and headache. Symptom relief does not rule out other serious stomach conditions. For further information, talk with your child's healthcare provider and click here for complete Prevacid prescribing information.