Title Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.
* First Name
* Last Name
* Email Address
* Phone Number
Cell Phone Number
Office Phone Number
Street Address
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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):
Which HRT drugs have you taken?Prempro (estrogen & progestin)Premarin (estrogen)Premphase (estrogen & progestin)Provera (progestin)Other
Date you started taking the drug (mm-yyyy):
Date you stopped taking the drug (mm-yyyy):
Were any of the following problems experienced during or after taking HRT medication?Heart AttackBreast CancerOvarian CancerGallbladder CancerSevere AsthmaSclerodermaLupusStrokeBlood ClotsPumonary Embolism
If you suffered any of the above conditions, what was your age when diagnosed?
If diagnosed with breast cancer, please indicate details of diagnosis:Breast cancer was hormone receptor positive for Progesterone.Breast cancer was hormone receptor positive for Estrogen.Lobular breast cancer was diagnosed.Ductile breast cancer was diagnosed.
Have you been genetically screened for breast cancer?YesNo
If you have been screened for breast cancer, please describe results:
Have any family members (sisters, mother, grandmothers) been diagnosed with breast cancer? YesNo
If yes, please describe which family member was diagnosed and the type of cancer that was diagnosed:
Please further describe side effects:
Other Info:
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