For information concerning the prescription drug Vioxx, complete the form below
and click Submit.
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Background Information

*Full Name:
*Address:
*City:
*State:
*Zip:
Email:
*Home Phone:
Work Phone:
Cellular Phone:
   

Vioxx Usage

Date you started taking Vioxx?:

  mm/dd/yyyy
What dosage was prescribed?
 
How often was Vioxx taken?
 
For what medical condition was Vioxx Prescribed?
 

Date you stopped taking Vioxx?

    mm/dd/yyyy
 

Prior to taking Vioxx, were you ever diagnosed with any of the following conditions?

Heart Attack

Yes: No: If Yes Year:

Heart Disease

Yes: No: If Yes Year:
Heart Arrhythmia Yes: No: If Yes Year:
Cardiomyopathy (weak heart muscle) Yes: No: If Yes Year:
Mitral valve disease Yes: No: If Yes Year:
Abnormal EKG Yes: No: If Yes Year:
Stroke Yes: No: If Yes Year:
High blood pressure Yes: No: If Yes Year:
 

Did you suffer any of the following damages/injuries while taking Vioxx?

Heart attack: Yes: No:  
Stroke: Yes: No:  

Other medical problems?

What dosage of Vioxx was taken when damage/injury occurred?

 

Did you ever take two(2) dosages at once?

  Yes: No:  

If yes did your doctor ever advise you to double your dosage?

  Yes: No:  

After taking Vioxx, was an EKG performed?

  Yes: No:  

If yes what were the results of the EKG?

 

Hospitalizations caused by Vioxx, including name and address of hospital, date of admission and discharge, type of treatment (e.g., surgery, stent placement, etc.)

Please advise us of any other information you feel may be relevant and/or important to us in evaluating your potential cause:

 
   

Thank you for taking the time to complete this form.