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Levaquin Questionnaire

Personal and Confidential

Please complete the following information. if you cannot remember names, places, dates, or other details precisely, don't worry- we'll fill in the blanks later. all information provided is absolutely confidential and will not be provided to a third party without your consent.

I. CONTACT INFORMATION

1. Name of person completing this questionnaire:

2. Contact Information: Mailing Address:

Home Phone:

Work Phone:

Cell Phone:

Email:

3. If you are completing this form on behalf of someone else, please answer the following

What is your relationship to the injured person?:

Why are you completing this form on his/her behalf? (ex: death, disability, minor child...)

4. If the Levaquin user has died, please answer the following:

Date of Death:

Name of Personal Representatives or Executor:

Identify all know beneficiaries and their relationship to the decedent:

5. Emergency contact name:

Emergency contact number:

II. INJURED PARTY INFORMATION

6. Name of injured party if different from above:

7. Date of Birth:

8. Social Security Number:

9. Marital Status:

10. If married, name of Spouse:

11. Names of children (if any):

12. Occupation at time of injury:

13. Have you ever filed a lawsuit before:

If yes, please state the nature of the lawsuit, when it was filed, and the result:

As an adult, have you ever been convicted of a felony, or any crime involving fraud or dishonesty?:

If yes, please explain:

III. PRODUCT RELATED INFORMATION

15. Please provide information about ALL physicians, hospitals, or medical providers who prescribed Levaquin:

Medical Provider 1:

Medical Provider 1: :: Please include Name, Address, and Phone Number

Medical Provider 2:

Medical Provider 2: :: Please include Name, Address, and Phone Number

Medical Provider 3:

Medical Provider 3: :: Please include Name, Address, and Phone Number

Medical Provider 4:

Medical Provider 4: :: Please include Name, Address, and Phone Number

Medical Provider 5:

Medical Provider 5: :: Please include Name, Address, and Phone Number

16. Please provide information on ALL pharmacies where Levaquin was obtained:

Pharmacy 1:

Dosage:

Start Date:

Stop Date:

Reason for prescription:

Pharmacy 2:

Pharmacy 2: :: Please include Name, Address, and Phone Number

Dosage:

Start Date:

Stop Date:

Reason for prescription:

Pharmacy 3:

Pharmacy 3: :: Please include Name, Address, and Phone Number

Dosage:

Start Date:

Stop Date:

Reason for prescription:

Pharmacy 4:

Pharmacy 4: :: Please include Name, Address, and Phone Number

Dosage:

Start Date:

Stop Date:

Reason for prescription:

Pharmacy 5:

Pharmacy 5: :: Please include Name, Address, and Phone Number

Dosage:

Start date:

Stop Date:

Reason for prescription:

17. Did you ever recieve free samples of Levaquin?:

If yes, please discribe dosage and frequency of samples:

18. Please list all other medications you were taking at or near the time of taking Levaquin, including over-the-counter drugs:

19. Were you being given any type of steroids at or around the same time you were taking Levaquin?:

If yes, what kind of steroids were you taking?:

IV. INJURY INFORMATION

A. Tendon Injuries

20. Have you sufferd a tendon injury as a result of taking Levaquin?:

If no, go to question 28. If yes, please answer the following:

21. What kind of tendon injury were you diagnosed with? (ex. Tendonitis, Ruptured Tendon, etc.):

22. When was the first time you experienced a tendon injury that you believe was associated with the use of Levaquin?:

23. How long after taking Levaquin did you begin to suffer from or experience tendon complications?:

24. Please describe your tendon injury (ex. Achilles tendon rupture; tendonitis in hand, etc.)

25. At the time you first noticed tendon pain, were you engaged in any type of strenous activity?:

If yes, please describe:

26. Describe the treatment that you have recieved for your tendon injury:

27. Has any doctor ever told you that your tendon injury was permanent?:

If yes please describe:

28. Please list all tendon injuries you have had prior to using Levaquin:

B. Liver Injuries

29. Did you suffer any liver damage as a result of taking Levaquin?:

In no, please go to question 34. If yes, please answer the following:

30. Please describe your liver injury (ex. Elavated liver enzymes, hepatitis, liver failure, etc.):

31. When were you first diagnosed with a liver injury whick you believe was related to your use of Levaquin?:

32. Have you had abnormal liver function tests after taking Levaquin?:

33. Please check any ailments that you have experienced:

Jaundice
Abdominal Pain
Dark Urine
Nausea
Vomiting
Distended Stomach
Clay-Looking Stool

34. Have you had any abnormal liver function tests prior to taking Levaquin?:

If yes, please state when and, if known, the reason why your enzymes were elevated:

C. Rashes, Blisters, and Serious Skin Reactions

35. Were you diagnosed with Stevens-Johnson Syndrome, Pemphigus Vulgaris (PV), or another serious skin reaction as a result of taking Levaquin?:

If no, go to question 39.

If yes, please describe:

36. When were you first diagnosed with this skin condition?:

37. Has your adverse skin reaction resolved?:

If yes, please state how long you experienced the condition before it resolved:

38. What type of treatment have you recieved for your skin condition?:

D. Other Levaquin-Related Injuries

39. Do you believe you have suffered any other injury as a result of your use of Levaquin?:

If yes, please describe:

40. When did you first suffer from injury described above?:

V. MEDICAL TREATMENT

41. Please provide us with the following information regarding any hospital, emergency, room, or urgent care clinic where you were treated for any injuries which you believe are related to your use of Levaquin:

Hospital or Clinic 1:

Name of Hospital:

Address:

Treatment sought:

Date of Treatment:

Hospital or Clinic 2:

Name of Hospital:

Address:

Treatment sought:

Date of Treatment:

Hospital or Clinic 3:

Name of Hospital:

Address:

Treatment sought:

Date of Treatment:

42. Please provide us with the following information for any doctor, osteopath, naturopath, chiropractor, physical therapist, or any healthcare provider who treated you for a Levaquin injury:

Healthcare Provider 1:

Name of Healthcare Provider:

Address:

Treatment sought:

Date of Treatment:

Healthcare Provider 2:

Name of Healthcare Provider:

Address:

Treatment sought:

Date of Treatment:

Healthcare Provider 3:

Name of Healthcare Provider:

Address:

Treatment sought:

Date of Treatment:

43. Please briefly describe your medical history prior to taking Levaquin:

44. Has a physician associated your injury with the Levaquin you were prescibed?:

If yes, please state which doctor, what he/she said and when:

45. When was the first time you believed that your injury was associated with the use of Levaquin?:

46. Where were you living at the time of your Levaquin-related injury?

VI. ECONOMIC AND OTHER LOSSES

47. Did you miss time from work due to your Levaquin injury?:

If yes, how much time was missed?:

Salary:

What limitations do you have as a result of your Levaquin injury?:

49. Did you have private health insurance that paid for all or part of you medical bills?:

If yes, please provide insurer's name:

Insurance I.D. number:

Are you currently, or have you ever recieved benefits through the Medicare program?:

If yes, please provide Medicare I.D. Number:

Date you enrolled in the program:

Are you currently, or have you ever recieved benefits through the Medicaid program?:

If yes, please provide Medicaid I.D. Number:

Date you enrolled in the program:

Please provide any useful details concerning what has happened to you as a result of using Levaquin and how this has affected your life in the text area below. Please be as pecific as possible.

Thank you for taking the time to complete this questionnaire. Please click the "Submit" button below to submit your questionnaire.

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