Crestorquestionnaire.pdf

CRESTOR QUESTIONNAIRE
GENERAL INFORMATION
_____________________________________________________ _____________________________________________________ _____________________________________________________ Mobile Telephone or e-mail address: __________________________________________ Social Security No.: ___________________________ Spouse’s Date of Birth: _______________ Social Security No. __________________ NOTE: If you are completing this form for a friend or family member, please provide the following information: Name and relationship to injured person: _____________________________________________________________ _________________________________________________ _________________________________________________ H: ___________________ W: ____________________ INFORMATION CONCERNING CRESTOR USE
Did you receive a recall letter from your physician or pharmacist? Do you still have receipts for your purchases of Crestor, a pill bottle or any remaining pills? Be sure to keep all containers and pills in a safe place until you turn them over to us. DO NOT RETURN PILLS OR BOTTLES TO THE PHARMACY
OR DRUG COMPANY.
Please list any other brands of statins (cholesterol lowering medications) you have taken and the dates of you took them: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ When were you diagnosed with Rhabdomyolysis? Physician or medical provider that made the diagnosis: Telephone: ____________________________________ If the diagnosis was made at a hospital or clinic, please provide: Do you have copies of any of the bloodwork or lab reports?_____________ Where was the bloodwork or testing performed? Please list the names and addresses of each pharmacy where you purchased Crestor. What are your current symptoms and for each symptom, please list the date it first appeared? Have you sought medical treatment for these symptoms? If so, please list the names and addresses for each physician and note the specialty area of practice for each physician (for example: cardiologist, rheumatologist, etc.). Have you been hospitalized at any time for these symptoms? If so, please provide: Have you undergone any recent medical testing such as blood work, liver profiles or dialysis? If so, when and where? Please provide a detailed medical history, including any and all illnesses or diseases. Please list the names, addresses and telephone numbers of all physicians or health care
providers you have seen in the last 10 years, including well check ups, annual physicals,
yearly examinations, employment physicals. Also, please provide a summary of
treatment rendered.
Please list the names, addresses and telephone numbers of all hospitals or clinics, both
in-patient and out-patient, where you have received treatment over the last 10 years.
Also please provide a summary of the treatment or testing performed at the facility.
What was your approximate weight when you began taking Crestor? Have you had any reactions or been hypersensitive to any other statin or cholesterol lowering medication? Do you have a history of liver problems or disease? Have you ever been told you have hematuria or blood in your urine? Do you have a history of renal (kidney) problems or disease? Have you ever been told you have proteinuria, albuminuria or protein in your urine? While taking Crestor did you experience muscle pain, weakness or muscle cramping? Have you been diagnosed with myopathy, myositis or myalgia (any pain or disease of the muscles)? Have you been diagnosed with cancer, leukemia, rheumatoid arthritis, lupus erythematosus, mycosis fungoides or vasculitis? While taking Crestor, did you take cyclosporine (Cytoxan or cyclosphosphamidine)? Have you ever been diagnosed with hypothyroidism? Have you or any members of your family been diagnosed with hereditary Have you been previously diagnosed with muscle toxicity? Have you ever been diagnosed with alcohol abuse? While taking Crestor, did you also take Gemfibrozil or Lopid or another medication to lower triglyceride levels? Were you provided any information concerning Crestor? For example, pamphlets, testing procedures, adverse effects, etc What did your physician tell you about Crestor? Have you been contacted by any federal, state or local health agencies concerning your Crestor usage? Have the manufacturers, distributors or pharmacies contacted you concerning Crestor? If so, when? Do you have copies of any correspondence? Have any of your physicians informed you that your problems are a result of ingesting Cestor? Have any of your bills been paid in whole or in part by insurance? If yes, in the space provided please list the names and addresses of your insurance carrier(s):

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