Contact Information:

*Title: -- Mr. Mrs. Ms. Miss Mr. & Mrs. Dr. *First Name: MI: *Last Name: *E-mail Address: *Retype = E-mail: Home Phone: - - Mobile Phone: - - Work Phone: - - ext.   *Provide at least 1 phone number. Street = Address: Apt/Suite: City: State/Zip: /   What is the best way to reach you? Please provide the best place, time and method for contacting you.   Additional Contact Information: Use this area to add country codes, foreign addresses, 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 2004 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 If you are NOT inquiring on your own behalf, what is your relationship? Is the person deceased? Yes No If deceased, the cause of death as stated on the death certificate:  Date 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 2004 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 Was there an autopsy performed? Yes  No  n/a

Case Information :

During what period of time was Vioxx prescribed? Start End Why was Vioxx prescribed? What dosage of Vioxx were you prescribed daily? (i.e. 25mg, 50mg, 75 mg) List names/addresses of any doctors who prescribed Vioxx: Did effects from Vioxx include: Heart Attack Yes No Stroke Yes No Blood Clots Yes No Deep Vein Thrombosis Yes No Pulmonary Embolism Yes No Death Yes No Other medical problems since Vioxx usage: Other Information: