| Do
I have a Serzone Case? |
| First
Name:
|
|
| Last 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: |
|
| Whom
are you inquiring on behalf of? |
|
| Is
the person deceased? |
Yes
No |
|
If deceased, the cause
of death as stated on the death certificate: |
|
| If
deceased, date
of death: |
|
| 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 |
| Describe
any other injuries or negative effects associated with Serzone use: |
|
|
Other
Information:
|
|
|
** Click on the "Disclaimer" link below for Terms.
|
