Parker, Waichman, Alonso LLP

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Date of birth of person injured
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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 Attack
Breast Cancer
Ovarian Cancer
Gallbladder Cancer
Severe Asthma
Scleroderma
Lupus
Stroke
Blood Clots
Pumonary 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?
Yes
No

If you have been screened for breast cancer, please describe results:

Have any family members (sisters, mother, grandmothers) been diagnosed with breast cancer?
Yes
No

If yes, please describe which family member was diagnosed and the type of cancer that was diagnosed:

Please further describe side effects:

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