| * Your name |
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| * Preferred e-mail address |
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| * Please confirm e-mail address |
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| * Your phone number |
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| * Your address |
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| Name of Injured (or deceased) person |
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| Your relationship to the injured person (if not you) |
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| If individual is deceased, date of death |
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| Cause of death on the death certificate |
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| Questionnaire |
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| 1. * When was Vioxx first prescribed? |
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| 2.* Were other medications being taken at the same time as Vioxx? |
Yes
No
Not Sure
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| If yes, which medications? |
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| 3.* While taking Vioxx, which side effects were experienced? (check all that apply) |
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Heart Attack |
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Stroke |
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Deep Vein Thrombosis |
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Blood Clots |
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Pulmonary Embolism |
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Death |
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Other, describe |
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| 4. * Has a health care provider said that these symptoms were/are related to Vioxx? |
Yes
No
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5. * Has a health care provider given another cause for the symptoms? |
Yes
No
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If yes, describe |
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6. * Was there any prior personal history of these symptoms? |
Yes
No
Not Sure
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If yes, describe |
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7.* Is there a family history of any of these symptoms? |
Yes
No
Not Sure
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| If yes, describe |
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| In order to insure that your questionnaire is received by lawyers in your local community, please select the city closest to you. |
* City |
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