Risperdal research resources: financial, patient safety, FDA

Please take the time to answer the questionnaire if you have or have had gynecomastia or other side effects from Risperdal� and are interested in learning more about your legal rights against Janssen, the manufacturer of Risperdal�. Your inquiry is appreciated and we will follow up with you shortly.

First Name of Injured Person
Last Name of Injured Person
Your Name (If not the same)
Relationship to Injured Person
Age of person taking Risperdal
Gender of person taking Risperdal	Male Female
Daytime Phone Number	( ) - ext.
Night Phone Number	() - ext.
Cell Phone Number	() - ext.
Email Address
Address
Address
City
State
Zip

Developed gynecomastia (woman-like breasts on a male) -OR- Early development of breasts in young girls? while on Risperdal?	Yes	No
Developed diabetic ketoacidosis while taking Risperdal?	Yes	No
Developed diabetic hyperglycemia while taking Risperdal?	Yes	No
Developed diabetic glucose abnormalities while taking Risperdal?	Yes	No
Developed diabetic diabetic-induced heart attack or coma while taking Risperdal?	Yes	No
Developed diabetes while taking Risperdal?	Yes	No
Diabetes before taking Risperdal?	Yes	No
Did child become agitated while on Risperdal�?	Yes	No

Develop any other health problems while on Risperdal?	Yes	No
Please describe:

Are you still taking Risperdal?	Yes	No
Date Started taking Risperdal:
Date Stopped taking Risperdal:

Have you ever taken Zyprexa�?	Yes	No
If you remember, then please tell us the approximate dates.
Have you ever taken Seroquel�?	Yes	No
If you remember, then please tell us the approximate dates.

Have you ever taken Geodon�?	Yes	No
If you remember, then please tell us the approximate dates.

Current Height
Current Weight

How much weight did you gain while on Risperdal�?
Was gynecomastia it in one or both sides of your chest?

What has your doctor told you was the cause of the Gynecomastia?


Does your child still have gynecomastia?	Yes	No
If not, how did your child get rid of it?

If your child had surgery to correct it:

How old was your child when they had surgery?
How long had your child had gynecomastia?
Were there post surgery complications?
Are you happy with the results?

If it started in childhood/adolescence how did it impact your child?

Did anyone else in your family have it? Father, brothers, uncles, grandfather, etc.?

Please let us know if you would like further information:

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