PROVOSTUMPHREY LAW FIRM
Xarelto Questionnaire
Date:______
Personal Information
Name:______
Street Address:______
City/State/Zip:______
Home Phone:______Work/Cell______
Email Address:______
SS#: ______DOB: ______
Spouse:______SS#:______DOB:______
Death Information (If Applicable)
Date of Death:______Decedent’s DOB ______Decedent’s SSN: ______
Did the death occur in the person’s resident state: ___ Yes; ___No
If not, what state did the death occur and why?______
______
Cause of Death:______
Has a Will been executed? ___ Yes; ___No
Has an Estate been opened? ___ Yes; ___No
*Please provide copies of the death certificate, will and any probate related documents*
VERY IMPORTANT!!
The information you provide here could have a bearing on the Statute of Limitations in your potential case. PLEASE NOTE: We cannot determine the Statute of Limitations in your case until we receive this questionnaire and obtain your medical records.
When did you learn that this medication was the cause of your disease/condition?
Specific Date: ______
How did you learn that this medication was the cause of your disease/condition? (T.V., newspaper, magazine ad, etc.) ________
______
Injury Information
Have you been diagnosed with any of the following injuries/conditions? Please check all that apply and provide the appropriate information:
Brain Hemorrhaging/Bleeding: ___ Yes ___No; Date of Diagnosis:______
Gastrointestinal Bleeding:___ Yes ___ No; Date of Diagnosis:______
Kidney Bleeding: ___ Yes ___ No; Date of Diagnosis:______
Internal Bleeding:___ Yes ___ No; Date of Diagnosis:______
Heart Attack/Cardiac Event: ___ Yes ___ No; Date of Diagnosis:______
Death: ___ Yes ___ No; Date of Death:______
For each injury/condition, please provide the following:
Name & address of the doctor that diagnosed you:
______
______
______
Name & address of the facility that provided treatment:
______
______
______
Prescription History
Please provide the name, address & reason that your doctor prescribed Xarelto (Rivaroxaban):
______
______
______
Please provide the appropriate information for each medication that you were prescribed.
Xarelto:
Start Date:______End Date: ______Prescriber: ______
Rivaroxaban:
Start Date:______End Date: ______Prescriber: ______
1. What side effects did the doctor who prescribed this medication tell you to expect?
______
______
______
2. Were you given any printed materials by any doctor or pharmacist regarding this medication? If so, list what you received.
______
______
______
3. Did you have any verbal communication/warning by any doctor or pharmacist regarding this medication? If so, please provide a summary of the conversation.
______
______
______
4. Have you previously had any recurrent stomach or intestinal bleeding?____Yes _____No.
If Yes, please list how many times, and dates.
5. Do you currently use aspirin, non-steroid anti-inflammatory drugs or Warfarin?
_____ Yes ______No
If yes, please list the name, the date you began the medication & how often you take it:
______
______
6. List ALL names, addresses, telephone number, date & reason on the chart for the following medical providers:
- ALL Doctors who prescribed this medication to you
- ALL Doctors who diagnosed your injury
- ALL Doctors who treated you for your injury
- ALL Facilities (hospital) where you received treatment for your injury – please include the type of treatment
Name of Doctor / Facility / Address / City / St / Zip / Phone # / Reason for Visit / Date
Example: John Smith, MD / 5522 Cool River Run / New York / NY / 12345 / 555-555-5555 / Dermatologist; prescribed Accutane / 1996-1998
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