* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date you started taking this drug:

Date you stopped taking this drug:

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?Yes
No

Was Tuberculosis (TB) diagnosed after taking Remicade?Yes
No

If yes, was Tuberculosis ever diagnosed before Remicade?Yes
No

Were the following side effects a problem while taking Remicade?Chest Pain
Bad Cough
Coughing Blood
Fever
Weakness
Weight Loss
Chills
Night Sweating
Confusion
Numbness
Vision Loss
Paralysis

Please further describe side effects:

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