Defendant: *

~Vioxx (heart attack and stroke) *

Describe Your Case: *

Have you or a loved one experienced Myocardial infarction?

Yes
No

Have you or a loved one experienced Unstable angina?

Yes
No

Have you or a loved one experienced Cardiac thrombus?

Yes
No

Have you or a loved one experienced Resuscitated cardiac arrest?

Yes
No

Have you or a loved one experienced Ischemic stroke?

Yes
No

Have you or a loved one experienced Transient ischemic attacks?

Yes
No

Date of Birth: (mm dd yy) *

Date of incident: *

How long have you used Vioxx? *

Has a loved one experienced sudden or unexplained death?

Yes
No

Do you have a copy of medical records?

Yes
No

Can you get a copy of medical records?

Yes
No

Were you or a loved one taking Vioxx at the time the injury was suffered?

Yes
No

If Vioxx was not being taken at the time of the heart attack, stroke, etc.; how many days were there between the last day Vioxx was taken and the heart attack, stroke, etc.? *

State dates of Vioxx use:

from when (month, day, year):*
to when (month, day, year): *

Your Information

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Last Name:	*
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