Microsoft word - zyprexa questionnare - word 97-2003 version.doc

Pursuant to our phone conversation, please answer the following questions so that Dr.
Krebs can better assist you.
PERSONAL INFORMATION
Other Phone:
ZYPREXA INFORMATION
For what reason did your doctor prescribe Zyprexa?
Do you suffer from any of the following conditions? (Please check all that apply)
Date you began taking Zyprexa:
Date you stopped taking Zyprexa:
Did a doctor say that you or a family member has a health condition caused by using Zyprexa?
Has a doctor diagnosed you or a family member with any of the following?
Date of Diagnosis:
When did you start noticing these conditions?
Has a family member died from any of the above Zyprexa side effects?
If yes, what date?
Please be specific and tell us about your Zyprexa side effects and risks. Also enter any questions or
comments in this space:
As a result of Zyprexa, did you suffer a new onset of Diabetes, requiring oral medication?
Please indicate if you have been prescribed to take any of the following medications: (Check all
that apply)
Can your diabetes be controlled by diet alone?
Has hospitalization been required for Pancreatitis?
Has Ketoacidosis resulted in hospitalization, coma or death?
Has a pre-existing diabetic condition worsened while on Zyprexa, requiring new medication or
insulin?
ADDITIONAL INFORMATION
Please be specific and tell us about your Zyprexa side effects and risks. Also enter any questions or
comments in this space.
How were you referred to this office?
Please make note that under current Texas law, you appear to have two (2) years from the date of occurrence in which to file a lawsuit. However, the Texas Supreme Court periodicallychanges the law and circumstances affecting the statute of limitations for various types of cases,which may effect when the statute of limitations in your particular case will run. Remember –under Texas law you are forever prevented from filing a lawsuit unless it is done within thedeadlines set out above.
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Source: http://www.krebslaw.com/publications/Zyprexa.pdf