Drug Litigation
 
Vioxx Information Form

1. Are you providing information for yourself or someone else?
Self        Age:
Someone else

2. If you are providing information for someone else,

  • Is this person living?
    Yes       Age:
    No        Age at death:
  • What is your relationship to the person?
  • What is the person's name?

3. Did you or the person you are providing information for have one or more of the following while taking Vioxx?

  • Heart attack
    Yes      When?
    No
  • Stroke
    Yes      When?
    No
  • Pulmonary embolism
    Yes      When?
    No
  • Deep vein thrombosis
    Yes      When?
    No

4. If there was no stroke, heart attack, pulmonary embolism, or deep vein thrombosis, what condition do you think might be related to taking Vioxx?

5. During what period of time was Vioxx taken?

6. What was the daily dose (in milligrams) of Vioxx?

7. Please enter the following information:
Name:
Address:
Phone:
Email:

8. If there is something you want to add, or if you have a question, enter it here.

 

 

 

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