VIOXX BASIC SCREENING QUESTIONNAIRE

Please complete the form below.

Note: fields with a (*) are required.

* Name:

Spouse's Name:

* Address:

* Age:

* Birthdate:

* Phone Number (Home) :

- - X

Phone Number (work):

- - X

Phone Number (cell):

- - X

* E-mail Address:

When did you start taking Vioxx:

When did you stop taking Vioxx:

Dose Of Vioxx:

Please describe any medical problems you had while taking Vioxx:

Have you had severe depression while you were taking Vioxx. If so please describe the event.

Has any physician told you that the medical problem you had while taking Vioxx was related to Vioxx.

List any other medications taken while taking Vioxx:

Family history of depression (parent, sibling, aunt, uncle, grandparent; please give best estimate of age of event)

Yes No

Free Consultation - NO Recovery - NO FEE CALL 24hrs TOLL FREE 888-890-HURT (4878)