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?
Yes
No

What date did stroke or hemorrhage occur?

If yes, what type of stroke/brain hemorrhage was suffered?
Hemorrhagic
Ischemic

If you checked Ischemic, did injured party have Atrial Fibrillation?
Yes
No

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?
Yes
No

What additional medications were you taking at the time?

Have you taken the diet drug Meridia?
Yes
No

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?
Yes
No

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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