Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
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Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

What additional medications were you taking at the time?

Was Gemfibrozil (Lopid) taken while taking Baycol?
Yes
No

Has Rhabdomyolysis been diagnosed?
Yes
No

Have any of the following side effects occurred?
Muscle Pain
Liver Problems
Kidney Problems
General Weakness
Dark Urination
Malaise
Nausea
Death

Please further describe side effects:

Other Info:

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