This questionnaire is intended to provide basic information necessary to evaluate the merits of any claim for compensation that you may have arising from your Trasylol injection. This information will be used for no other purpose and will be kept strictly confidential as required in any attorney/client relationship. However, completion and submission of the questionnaire does not establish such a relationship and no obligations of any kind exist between you and the Law Offices of Rodney A. Klein or the Law Offices of Lawrence S.Paikoff, until further discussions and agreements are reached between the parties and a fee agreement is signed.

Please complete this questionnaire to the best of your ability with as much detail as possible. Required information is indicated in red with an asterisk ("*").

Part I: Personal Information

Please complete this form with the information for the person believed to have suffered damages due to this product.

1. Your current first*, middle, and last* names:
   
   
   
2. All former names (if any) and the years used:
   
   
   
3. Current mailing address:
   
   
   
4. City, State, Zip
   ,
   
   
5. Preferred E-mail address*:
   
   
   
6. Daytime telephone number with area code*:
   e.g. 555-555-1212
   
   
7. Evening telephone number with area code:
   e.g. 555-555-1212
   
   
8. Fax number with area code:
   e.g. 555-555-1212
   
   
9. Date of Birth*:
   e.g. MM/DD/YYYY
   
   
10. Social Security Number:
    e.g. 000-00-0000
    
    

Part II: Medical Information

If you are uncertain of dates, names, addresses, et cetera, please submit the questionnaire, and we will obtain any other necessary information at a later time.

11. Approximate date of your first Trasylol injection:
    e.g. MM/DD/YYYY
    
12. Physician's name:
    
13. Name of the Hospital where the injection was given:
    
    
14. Address of the Hospital (if known):
    
15. Have you received a letter or call from your doctor regarding your Trasylol injection?
    
    
16. Have you received any letters or other contact from the manufacturer of Trasylol?
    Please Choose... Yes, I did. No, I did not. I don't know.
    
    
17. Have you had second injection? If not, please skip to the next question.
    Please Choose... Yes, I did. No, I did not. I don't know.
    
    
18. 1. Approximate date of your second injection:
       e.g. MM/DD/YYYY
       
       
    2. Physician's name:
       
       
       
    3. Name of the Hospital where the injection was given:
       
       
       
    4. Address of the Hospital (if known):
       
       
       
19. Have you been told by your physician that your injury could have been caused by the Trasylol injection you received? If not, please skip to the next question.
    Please Choose... Yes, I did. No, I did not. I don't know.
    
    
    

Part III: Symptoms

For each of the following symptoms, please indicate which you have experienced.

Part IV: Comments

Please feel free to write any additional comments in the section below that you feel may be important. This can be supplemental information about something above, or any other issue relating to your Trasylol injection.