FREE CASE REVIEW
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Details of Your BEXTRA Legal Case
When did use of Bextra start?
When did use of Bextra end?
Dose of Bextra:
Please describe any medical problems you had while taking Bextra:
Have you had a cardiovascular event or stroke while
you were taking Bextra? If so, please describe the event:
List any other medications taken while taking Bextra:
List any heart or blood pressure medications:
Your weight:
Family history of heart disease/stroke:
(parent, sibling, aunt, uncle, grandparent;
please give best estimate of age of event)
Personal history of previous heart attacks:
Personal history of stroke:
Personal history of elevated cholesterol/triglycerides:
(please note if anti cholesterol medication and/or diet
treatment):
Personal smoking history:
Personal history of High Blood Pressure (Hypertension):
Personal history of chest pain/angina:
Personal history of congestive heart failure:
Personal history of phlebitis:
(also called thrombosis or thrombophlebitis;
it basically means blood clots in the veins)
Case Description*
Please explain the details of your case:
Comments / Additional Information.
Is there anything else that would assist us in understanding the facts of your case?
Has any physician told you that the medical problem
you had while taking Bextra was related to Bextra?
Yes
No
Do Not Know
What symptons did you, or the deceased patient, experience while using Bextra?
When did you start to experience these symptoms?
Did you report these symptoms to a doctor?
Yes
No
Do Not Know
Did you have a gastrointestinal bleeding while taking Bextra?
Yes
No
Do Not Know
If Yes, when?
Have you been diagnosed with Stevens-Johnson Syndrome?
Yes
No
Do Not Know
Did the doctor/hospital tell you to stop taking Bextra because of any of these problems?
Yes
No
Do Not Know
Were you admitted to the hospital for these symptoms?
Yes
No
Do Not Know
If Yes, when were you hospitalized?(month/year)
If Yes, how long were you hospitalized?(days)
If Yes, where were you hospitalized?
Please Note: Statutes of limitation exist which limit the time period in which a case can be brought to trial. As such, it is important to know exactly when and where the incident occured.
(* ) This is a required field
Your Contact Information
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* Last Name:
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Do you currently have an Attorney
No
Yes
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