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Personal Injury Case Facts

1. Has a doctor said that you have a medical condition or disease caused by one or more prescription drugs? YesNo

If yes, please indicate which condition(s) or disease(s) the doctor diagnosed; check all that apply:

2. What was the date of the initial diagnosis:

3. What is your date of birth:

4. Have you filed a lawsuit concerning your drug-related condition or disease?YesNo

5. Please list below the prescription drug(s), followed by dosage information (example: 10 mg pill 2 times per day), that you were taking just before the onset of the drug-related condition or disease:

Wrongful Death Case Facts

1. Was a drug-related condition or disease possibly involved with the death of a family member or someone else you know?YesNo

If yes, please indicate which condition(s) or disease(s) the doctor diagnosed before or at the time of death; check all that apply:

2. What was the date of the initial diagnosis:

3. Have you or someone else filed a lawsuit concerning this death?YesNo

4. What was the date of death?

5. Please list below the prescription drug(s), followed by dosage information (example: 10 mg pill 2 times per day), that you were taking just before the onset of the drug-related condition or disease:

Is there any additional information you would like to include?

Please enter any additional information about this claim, as well as any comments or questions you may have, in the following space: