QUESTIONNAIRE FOR RAPTIVA USERS
If you feel you have been injured by Raptiva please consider and complete the questionnaire below.
Please telephone, email or fax your answers to:
Attorney Wayne Hassay
Maguire & Schneider, LLP
250 Civic Center Drive, Ste 500
Columbus, OH 43215
phone: 614-224-1222 or 800-600-1222
fax: 614-224-1236
Name: ________________________________________________
Address: ________________________________________________
________________________________________________
E-mail Address:________________________________________________
Home Phone:______________________ Work Phone:____________________________
Social Security #:_______-_______-________ Date of Birth:______-_______-______
Date of Death (if applicable):___________________
Employer:________________________________ Job Title:____________________________
Employer Address: _______________________________________
_______________________________________
Number of Years Employed:___________________ Salary:_________________
Marital Status: Spouses Name:___________________________
Spouse's Social Security #:______-____-_______ Date of Birth:_______-_______-______
Spouse's Employer:______________________________ Job Title:___________________________
Spouse's Business Phone:_______________________________
Children (names & ages): ___________________________________
___________________________________
ALTERNATE CONTACT PERSON (Outside your household)
Name:_______________________________ Home Phone #:_______________
Email Address:________________________ Work Phone #:________________
Address:_____________________________________________________________________________
Relationship to you:____________________________________
MEDICAL HISTORY:
Date started Raptiva: ___/___/_____
Date discontinued Raptiva: ___/___/_____
Physician Name/Address who prescribed Raptiva: _________________________________________
____________________________________________________________________________________
Describe medical condition or reasons why you started Raptiva: __________________________________
____________________________________________________________________________________
____________________________________________________________________________________
What did the Physician tell you, if anything, about the risks of Raptiva: ___________________________
____________________________________________________________________________________
Name and address of all pharmacies where you had a prescription of Raptiva filled: _________________
____________________________________________________________________________________
____________________________________________________________________________________
Were you ever given Raptiva directly from the Physicians office: ___ yes ___ no
If yes, name/address of Physicians office: ________________________________________________
____________________________________________________________________________________
List all other medications you were taking when you were taking Raptiva: _________________________
____________________________________________________________________________________
____________________________________________________________________________________
Current Physician(s)/facilities treating you for injuries from Raptiva:_______________________
____________________________________________________________________________________
____________________________________________________________________________________
(name) (address)
Have you been diagnosed or experienced any of the following conditions:
if yes, mark one (1) if diagnosed before taking Raptiva; and two (2) if diagnosed during or shortly after taking Raptiva
Bacterial Sepsis ____yes ___no date of diagnosis ___/____/____
Viral Meningitis ___ yes ___ no date of diagnosis ___/___/___
Invasive Fungal Disease ___ yes ___ no date of diagnosis ___/___/___
PML ___ yes ___ no date of diagnosis ___/___/___
Other Infections ___ yes ___ no date of diagnosis ___/___/___
If so, what type of infection(s)________________________________________________
Any Immune Deficiency Disease ___yes ___no date of diagnosis__/___/___
If so, what type of disease(s)______________________________________
While taking Raptiva, did you ever experience the following conditions?
Weakness in one side of body _____yes ____no
Loss or Blurred Vision _____yes ____no
Fatigue _____yes ____no
Memory Loss _____yes ____no
Disorientation _____yes ____no
Loss of Balance _____yes ____no
Do you have any other health condition which you believe was caused by the medication Raptiva? If so,
state condition, symptoms and the date this occurred:______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Did a Physician ever tell you that you were injured as a result of taking Raptiva: ____ yes ____ no
If so, when: ___/___/___
Family History: Mother, Father, Sisters, Brothers; Alive & Well?_____________________________
____________________________________________________________________________________
Major Illnesses among family members:__________________________________________________
____________________________________________________________________________________
Previous Illnesses/prior Hospitalizations:___________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Present Family Physician: (address & phone #):______________________________________________
____________________________________________________________________________________