Name:
Address:
City:
State:	Zip:
Phone:	Email:
Please contact me by Phone Email in the Morning Afternoon Evening

 

Injured Person Information:

Whom are you inquiring on behalf of?	Self Other
If you are not inquiring on your own behalf, what is your relationship?
Is this person deceased?	No Yes
If yes, what is the cause of death as stated on the death certificate:

 

Case Information:

What medication was prescribed:
Date medication prescribed:
Name of prescribing doctor:
Reason for use of medication:
How long did you use the medication?
Side effects from use of medication:   Abdominal Pain Hair Loss Lymphoma Acne Headaches Mental Illness Addiction Heart     Problems /     Attack Nausea /     Vomiting Birth Defects High Blood     Pressure Overdose Bone, Joint, &     Muscle Disorders Hypertension Poisoning Coma Irregular     Periods Pregnancy     Complications Death Jaundice Respiratory     Depression Decreased     Interest in Sex Kidney     Damage /     Failure Seizures /     Convulsions Digestive     Disorders Liver Problems Stevens     Johnson     Syndrome Gallbladder     Problems Loss of     Appetite Stroke Gastrointestinal     Complaints Lung & Airway     Disorders Weight     Changes
Date(s) of injury
Did you require medical attention?	No Yes
If yes, describe:
Where did you purchase your prescription? (name and location)
Do you have: Receipts showing purchases? No Yes Copy of prescription that was written for you? No Yes Container that the prescribed medication came in? No Yes
Please list any other medications used in conjunction with this one?

 

Other Information:

Please list any other information or questions.

I agree that the above does not constitute a request for legal advice and I am not forming an attorney-client relationship by submitting this questionnaire. I understand that I may retain an attorney only by entering into a separate fee agreement. As such, I will not be charged for the initial response to this questionnaire and I understand that the response I receive should be considered only as general information, and not as legal advice. I also understand that the law for each state may vary and that this matter may be referred to an attorney in my area who may contact me.