If you are responding for an Avandia user who has died of a heart attack or stroke:

Decedent's Name

What was the date of death?

Cause of death?

Age of the decedent?

When were you diagnosed with Diabetes?

How long have you been taking Avandia?

What dosage were you taking? mg per day

Has your physician told you to stop taking Avandia? Yes No

What is your date of birth?

Have you been diagnosed as having any of the following while taking Avandia?

Have you experienced any of the follow symptoms while taking Avandia?

Prior to taking Avandia had you been under the care of a cardiologist? Yes No

Prior to taking Avandia had you been diagnosed as having a heart attack or stroke?

Were you taking medication for any of the following prior to or while you were taking Avandia?

High blood pressure
High cholesterol
Blood thinners
Nitroglycerine

Have you had any of the following tests:

EKG	Date:
Echocardiogram	Date:
Angiogram	Date:
Angioplasty	Date:
Stress Test	Date:
Thallium Stress Test	Date: