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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):
Why was Remicade prescribed? (arthritis, crohn's disease, etc.)
If Demyelination was diagnosed while taking Remicade, please describe diagnosis:
Was Lymphoma diagnosed after taking Remicade? YesNo
Was Tuberculosis (TB) diagnosed after taking Remicade? YesNo
If yes, was Tuberculosis ever diagnosed before Remicade?YesNo
Were the following side effects a problem while taking Remicade? Chest PainBad CoughCoughing BloodFeverWeaknessWeight LossChillsNight SweatingConfusionNumbnessVision LossParalysis
Please further describe side effects:
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