Parker, Waichman, Alonso LLP

Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
-Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-

Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

What condition was this medication prescribed to treat?

Did a heart attack occur within one year of taking Premphase or Prempro?
Yes
No

Were any of the following problems experienced during or after taking HRT medication?
Heart Attack
Breast Cancer
Ovarian Cancer
Gallbladder Cancer
Severe Asthma
Scleroderma
Lupus
Stroke
Blood Clots
Pumonary Embolism

If you suffered any of the above conditions, what was your age when diagnosed?

What was the date of diagnosis?

Please describe diagnosis:

Please describe history of HRT drug prescriptions (please provide date and drug used in chronological order):

If diagnosed with breast cancer, please indicate details of diagnosis:
Breast cancer was hormone receptor positive for Progesterone.
Breast cancer was hormone receptor positive for Estrogen.
Lobular breast cancer was diagnosed.
Ductile breast cancer was diagnosed.

Have any family members (sisters, mother, grandmothers) been diagnosed with breast cancer?
Yes
No

If yes, please describe which family member was diagnosed and the type of cancer that was diagnosed:

Have you been genetically screened for breast cancer?
Yes
No

If you have been screened for breast cancer, please describe results:

Please describe history of blood clots and/or strokes:

Did you ever take Provera?
Yes
No

If yes, did you take Provera while taking Premphase or Premarin?
Yes
No

Please further describe side effects:

Other Info:

No Yes, I agree to the Parker Waichman Alonso LLP disclaimers.Click here to review all.

Yes, I would like to receive the Parker Waichman Alonso LLP monthly newsletter, InjuryAlert.