Vioxx Intake Sheet

NOTE TO SCREENER:

We are only taking cases with a diagnosis of:
Heart Attack, Stroke, Blood Clots, Steven's Johnson Syndrome.

No time limit on length of time taking VIOXX
If the injured died, death must be within the last 2 years
If it looks like a potential case, instruct the client that we will send them more information and ask them to retain all prescriptions/pills that they may have.

Date:		Screener:
Source: (TV Ad)		Other:
Relationship of Injured to Caller:		Self:

Injured's Name:
Injured's Date of Birth:
Injured's Gender:	Male Female
Injured's Address:
Injured's Phone #:
Injured's Work #:
Injured's Cell #:
Caller's Address/Phone Number:

VIOXX INFORMATION
Dose: (50 mg., 25. mg)		Pills Per Day:
Date Started:		Date Ended:

Reason for taking VIOXX:
Reason for ending VIOXX:

DIAGNOSIS: (Heart Attack, Stroke, Blood Clots, Steven's Johnson Syndrome)
Diagnosis:
Date of Diagnosis:
Notes on Diagnosis/Hospital/Stay/Cause:

If died, cause of death:

Date of Death:

Autopsy?:
Survivors:
Family history of heart disease:
Personal Medical History: (Prior Heart Problems, Hypertension, Diabetes, High Cholesterol, Smoking, etc.)
Medications:
Location of Medical Care (Kaiser?):

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