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 -Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-
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):
State where drug was ingested: -Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont -U.S. Virgin Islands- Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -Other-
What product(s) was/were used containing PPA?
Was the injury a stroke/brain hemorrhage? YesNo
What date did stroke or hemorrhage occur?
If yes, what type of stroke/brain hemorrhage was suffered?HemorrhagicIschemic
If you checked Ischemic, did injured party have Atrial Fibrillation? YesNo
How many days after using the PPA product did injured party suffer the stroke/hemorrhage?
How often was this medication used and when was it last used?
Does injured party still have this medication? YesNo
What additional medications were you taking at the time?
Have you taken the diet drug Meridia?YesNo
Please describe any residual damages resulting from stroke (paralysis, slurred speech, memory loss):
If stroke was suffered, has any doctor given his/her opinion as to the cause of the stroke?YesNo
If injured party did NOT have a stroke, what injuries were suffered as a result of PPA?
Please further describe side effects:
Other Info:
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