Intake Questions for Talcum Powder/Ovarian or other Gynecological Cancer case type:

· Client’s name, address, phone number, email, DOB, marital status and referral source information.

· Did you use a Johnson & Johnson brand talcum powder product? If so, what is the name of the powder (i.e., Johnson’s Baby Powder or Shower to Shower)? Did you use the generic/store brand powder? (If client has any talcum powder remaining, they should keep it until further notice).

· How long has talcum powder been used? (secure from/to usage dates or from what age to what age)

· How often was the talcum powder used? (i.e., every day, twice per day, seasonally, or whatever times the powder was used per day or per week)

· How did you use the talcum powder? Was the powder applied directly to the genital area? Underwear? Feminine napkin? On diaphragm? Other?

· When were you diagnosed with ovarian cancer? (secure date) If not ovarian cancer, but other gynecological cancer, secure date of diagnosis and the type of cancer diagnosed.

· What is the contact information (name/address) for the physician that diagnosed you?

· How and when did you discover that the talcum powder could have caused or did cause your ovarian cancer? Has any doctor told you it was caused by the powder? If so, when?

· What treatment has been done for your ovarian cancer to date (or what treatment is the doctor recommending)?

· Is there a family history (others in the family) who were diagnosed with cancer (check for family history of breast, uterine, ovarian, endometrial, or any other gynecological cancer)? Have you ever been diagnosed with any other types of cancer? If yes, who (i.e., grandmother, mother, aunt, sister, etc.) and what type of cancer was diagnosed?

· Have you ever smoked? If so, when and how many cigarettes per day?

· Did you every take any tests to check your potential risk of cancer? Have you tested positive for a BRCA1 or a BRAC2 gene?

· If the case involves death, secure the date of death and cause of death listed on the death certificate. If a death case, ask how the contact person has the direct knowledge of the talcum powder usage.

Cohen, Placitella & Roth, P.C.

888-375-7600

Philadelphia, PA Red Bank NJ