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Free Vioxx Case Review

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Contact Information

First Name
Last Name
Home Phone - -
Work Phone - -
Cell Phone - -
Email
Confirm Email
Street Address
City
State
Zip

Case Information

Which drug was taken?
Start date
Stop Date
Your age when you started taking drug?
Do you have records from your doctor?Yes No
Do you have records from your pharmacy?Yes No
Do you have used or unused prescription bottles?Yes No
Why was the drug taken?
If other, please explain
Is the drug still being taken?Yes No
What is your dosage?
How often was the drug taken?
Is the drug still being taken?Yes No
Whay injuries have you suffered?
Check all that apply
Heart Attack
Stroke - Bleeding in Brain
Stroke - Blood Clot in Brain
Pulmonary Embolism/Lung Blood clot
DVT/Leg Blood clot
Blood Clots other
Mini-stroke or TLA
High Blood pressure Crisis
Liver Damage/Disease
Ulcer/Bleeding Event
Seizure
SJS (Stevens Johnson Syndrome)
TEN
Erythema Multiforme
If other, please explain
Date of injury
How long have you used the drug?
Have you had any gaps in usage?Yes No
When was your last dosage before the injury?
Name of doctor or treating physician
Doctors street address
Doctors phone - -
Do you have a family history of strokes?Yes No
Do you have a family history of heart problems?Yes No
Do you have a family history of bleeding?Yes No
Please list all of your current medical conditions
Please list all of your current medications
Please list ALL hospitalizations in the past 10 years

Do you dip chew?Yes No
If you do smoke, how many cigarettes per day?
Which cigarette brand?
In what year did you start smoking?
If you quit, what year did you stop smoking?
Which cigarette brand?
Did you smoke in the past?Yes No
Explain why you quit
Do you drink alcohol?Yes No
What kind of alcohol do you drink?
How many drinks per week do you have?
Have you been contacted by an attorney or law firm about your potential case?Yes No
What was the attorneys or lawfirm name?
When were you contacted?
Questions, comments, additional information

Disclaimers

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I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

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