* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date you started taking this drug:

Date you stopped taking this drug:

What condition was this medication prescribed to treat?

Did a heart attack occur within one year of taking Premphase or Prempro?Yes
No

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?

What was the date you were diagnosed with TTP?

Please describe diagnosis:

Please describe history of HRT drug prescriptions (please provide date and drug used in chronological order):

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 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:

Have you been genetically screened for breast cancer?Yes
No

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

Please describe history of blood clots and/or strokes:

Did you ever take Provera?Yes
No

If yes, did you take Provera while taking Premphase or Premarin?Yes
No

Please further describe side effects:

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