Name:
E-mail*:
(ex.
johndoe@anywhere.com)
Day
Phone*:
(ex.
505-555-5005)
Alt. Phone:
(ex.
505-555-5005)
Address:
City:
State / Zip:
/
(ex.
NY / 10005)
Additional Contact
Information:
Opt. country code,
special instructions, etc.
Injured Person
Information:
Date of Birth:
mm
01
02
03
04
05
06
07
08
09
10
11
12
dd
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Whom are you
inquiring on behalf of?
Minor
Other
Self
Is the person
deceased?
Yes
No
If deceased, the
cause of death as stated on the death certificate:
If deceased, d ate
of death:
mm
01
02
03
04
05
06
07
08
09
10
11
12
dd
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
yyyy
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
If deceased, was
there an autopsy performed?
Yes
No
Case
Information:
During what period of time was Serzone taken?
Start End
List
names/addresses of any doctors who prescribed Serzone:
Were any other
medications taken while taking Serzone?
Yes
No
If yes, please
list any other medications taken while taking Serzone:
Have liver
problems occurred since taking Serzone?
Yes
No
If yes, please
describe liver problems:
Have you had a
Liver Function Test (LFT) since taking Serzone?
Yes
No
If yes were the
LFT enzymes elevated?
Yes
No
If yes, what were
the results of liver enzyme tests?
Have liver
problems been diagnosed by doctor?
Yes
No
If yes, what was
the diagnosis?
Did suicidal
thoughts occur while taking Serzone
Yes
No
If yes, was
Suicide attempted
Yes
No