If you are responding for a Celebrex user who has died of a heart attack or stroke, please provide the following and address each question for the decedent:

Decedent's Name

What was the date of death?

Cause of death?

Age of the decedent?

How long have you been taking Celebrex?

What dosage were you taking?

200 mg per day
400 mg per day
800 mg per day
Other (Please specify)

Why were you prescribed Celebrex?

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

What is your date of birth?

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

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

Prior to taking Celebrex 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 Celebrex?

High blood pressure
High cholesterol
Blood thinners
Nitroglycerine

Have you had any of the following tests: