Vioxx Questionnaire

Office Locations

Tallahassee
(Map and Directions )
3375-A Capital Circle N.E.
Tallahassee, FL 32308
Toll Free Phone: (877) ALL WE DO
Local Phone: (850) 553-HELP
or (850) 422-7773
Fax: (850) 422-3449

Key West
(Map and Directions )
608 Whitehead Street
Key West, FL 33040
Toll Free Phone: (877) ALL WE DO
Local Phone: (305) 294-4585
Fax: (305) 294-7822

Thomasville
(Map and Directions )
214 West Jackson Street
Thomasville, GA 31792
Toll Free Phone: (877) ALL WE DO
Local Phone: (229) 226-HELP
(229) 226-4357

What should I do if I or a loved one took Vioxx?

Name:
E-mail:
Phone:
Address:
City:
State:
Zip:

How long have you been taking Vioxx?

What dosage were you taking?

12.5 mg per day
25 mg per day
50 mg per day
Other (Please specify

Why were you prescribed Vioxx?

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

What is your date of birth?

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

Heart attack	Date Diagnosed (month/year):
Stroke	Date Diagnosed (month/year):
TIA	Date Diagnosed (month/year):
Blood clots	Date Diagnosed (month/year):

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

Headache
Chest pain
Stomach pain
Jaw pain

Dizziness
Nausea
High blood pressure
Fatigue

Shortness of breath
Heart burn
Swelling of the feet or legs

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

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

Heart attack	Date:
Stroke	Date:

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

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:
Angioplasty	Date:

If you are responding for a Vioxx 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?