Avandia Class Intake Form

Date:*

Claimant's Name (Individual who was prescribed Avandia):

Name

First Middle Last

If Claimant is deceased, please check:

Claimant is Deceased

Date of death:

Claimant Address

Address:

Home Phone:

Facsimile:

Contact Address (If Claimant deceased):

Address:

Cell Phone:*

Email*

Remainder of this form pertains to information about the Claimant

Date of Birth:

Place of Birth:

Social Ins. #:

Health Card #:

Occupation:

Employer:

Retired

Yes
No

Marital Status:

Status

Single:	Married:	Common Law:

Status

Divorced:	Widowed:	Separated:

Date

Divorce Date:	Widowed Date:	Separated Date:

Spouse:

Name

First Middle Last

Date of Birth:

S.I.N. No.:

H.C. No.

Children

(Only to be completed if Claimant is Deceased):

1. Name

First Middle Last

Date of Birth:

S.I.N. No.:

H.C. No.

2. Name

First Middle Last

Date of Birth:

S.I.N. No.:

H.C. No.

3. Name

First Middle Last

Date of Birth:

S.I.N. No.:

H.C. No.

4. Name

First Middle Last

Date of Birth:

S.I.N. No.:

H.C. No.

History of use:

Took Avandia From	To

Dosage: How many mg?:

How many pills per day?:

Why was it prescribed?:

When were you first diagnosed with type 2 diabetes?:

Do you have receipts of purchase?:

Do you have any of the product and/or packaging?:

(If so, please keep any evidence of purchase)

Medical information:

Have you experienced any of the following while taking Avandia or after taking Avandia? Please check any that apply.

Fluid Retention
Congestive Heart Failure
Other Cardiovascular Issues
Swelling (Edema)
Shortness of Breath
Weakness
Fatigue
Weight Gain

Please provide details:

Have you suffered a heart attack, been diagnosed with congestive heart failure, liver complications and/or do you suffer any other side effects?:

Please note that we will never contact any persons listed below without your express consent. Family Doctor(s):

Provide details of doctors who would possess medical records related to medical conditions and/or treatment received arising from the use of Avandia:

Detail of Doctors

Name	Phone #	Address

Detail of Doctors

Name	Phone #	Address

Detail of Doctors

Name	Phone #	Address

Detail of Doctors

Name	Phone #	Address

Specialist(s):

Detail of Specialists

Name	Phone #	Address

Detail of Specialists

Name	Phone #	Address

Detail of Specialists

Name	Phone #	Address

Detail of Specialists

Name	Phone #	Address

Other Physician(s)/Hospital(s):

Provide details of any other medical practitioner or facility who would possess medical records related to medical conditions and/or treatment received arising out of the use of Avandia:

Detail of Physicians

Name	Phone #	Address

Detail of Physicians

Name	Phone #	Address

Detail of Physicians

Name	Phone #	Address

Detail of Physicians

Name	Phone #	Address

Pharmacies:

Provide details of pharmacies that would possess prescription records verifying that you were prescribed Avandia:

Detail of Pharmacies

Name	Phone #	Address

Detail of Pharmacies

Name	Phone #	Address

Detail of Pharmacies

Name	Phone #	Address

Detail of Pharmacies

Name	Phone #	Address

Provide details of any Medical Specialists you have seen regarding Avandia or for any complications arising out of the use of Avandia:

Please briefly describe any medical problems you had before taking Avandia, specifically cardiovascular problems:

If you have suffered any cardiovascular problems or a heart attack, did you ever have heart problems prior to taking Avandia?:

Have you been prescribed any other medication as treatment for Type 2 Diabetes? If you no longer take Avandia, were you prescribed a replacement medication?

Yes
No

If so what medications:*