* First Name 

   * Last Name 

   * Email 

Phone 

Cell Phone 

Street Address 

Zip Code 

City 

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Date you started taking this drug:

Date you stopped taking this drug:

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:

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