First Name
Middle Initial
Last Name
Street Address
Address (cont.)
City
Province
Postal Code
Home Phone
Work Phone
Email Address
Date of Birth (mm/dd/yy)
Health Card Number
Gender	MaleFemale
When were you first prescribed Vioxx?
Who was your prescribing physician?
Who is your family physician if different than above?
When did you stop taking Vioxx?
How did you find out to stop taking Vioxx?	Doctor: Yes No    Pharmacy: Yes No    Newspaper: Yes No    TV: Yes No    Merck Frosst: Yes No    Friend/Family: Yes No    Other: Yes No
Has Merck Frost or the pharmacy offered to reimburse you for the cost of the drug?	Yes No
If yes, have you received reimbursement?	Yes No
What dosage of Vioxx were you taking?	mg
Was the dosage increased at any time?	Yes No
If so, when and how much?
Were you prescribed any other medication to be taken in conjunction with Vioxx?
Name and address of pharmacy where prescription purchased?
Has a doctor or other medical professional ever told you that you suffer an illness related to your use of Vioxx?	Yes No
If yes, provide the names, addresses and phone numbers of all medical professionals, the illness diagnosed and the date you were told your illness was related to your use of Vioxx.
Has a doctor or other medical professional ever told you to stop taking Vioxx?	Yes No
If yes, provide the name, address and telephone number of the medical professional.
What illnesses or conditions are you suffering from today, if any?
Have you experienced or do you continue to experience any of the following symptoms since ingesting VIOXX:	High Blood Pressure: Yes No    Dizziness: Yes No    Swelling of the Extremities: Yes No    Chest Pain: Yes No    Vomiting: Yes No    Heart Condition: Yes No    Stroke: Yes No   Angina: Yes No    Fatigue: Yes No    Irregular Heart Beats: Yes No
Have you received medical treatment or been hospitalized for injuries sustained during or as a result of taking Vioxx?	Yes No
What kind of medical treatment did you receive?
Have you had heart surgery since the ingestion of Vioxx?	Yes No
Have you had heart stenting or angioplasty since the ingestion of Vioxx?	Yes No
All Treating Doctor's Names & Addresses
All Treating Hospitals Names & Addresses
Do you have family members who were affected by your experience taking Vioxx?	Yes No
Name & Relationship to you	Vioxx
Employment Information (if you are claiming lost wages) Employer (or last employer)
Employer Address and Telephone Number
Type of Employment/title
Dates missed from work due to injury or illness
Rate of pay