Baycol Questionnaire

If you are interested in exploring your legal options for a potential claim against the manufacturer of Baycol, please fill out as much as you can of the following form and click on the "Submit" button at the end of the form.

If you would like to discuss this questionnaire with a Client Relations representative, please just fill out your name, phone number and the best time to call.

Thank you.

Name:
Next of Kin (or Person Responding):
(relationship):
Address: Apt:
City: State: Zip:
Phone# :
Social Security# (optional):
Date of Birth (optional) :
Date of Death:
Marital Status:
Spouse's Name:
(Please provide if you would want your spouse to be included on the claim)
Best time to call:

A) Have you been diagnosed with Rhabdomyolysis?
YES NO
When?

Since taking Baycol, have you suffered from any of the following conditions?

B) Have you experienced any muscle pain in your lower back or calves?
YES NO
If yes, where?
Dates:
C) Have you experienced any other pains?
YES NO
If yes, where?
Dates:
D) Do you, or have you had any of the following symptoms: (check all that apply)
Nausea Severe Muscle Pain
Fever Weakness
Vomiting Tenderness
Dark Urine
E) While on or since stopping Baycol did anyone tell you that you had any abnormalities in a liver function test?
YES NO
If yes, Have you been diagnosed with any liver problem or damage?
When?
Diagnosis:
F) While on or since stopping Baycol did anyone tell you that you had
abnormalities in any kidney function tests?
YES NO
If yes, have you been diagnosed with any kidney problem or damage?
When?
Diagnosis:
G) Have you had abnormalities in any Blood or Urine Tests?
YES NO
If yes, when?
Diagnosis:
H) Has anyone ever told you that you have protein in your Urine?
YES NO
If yes, when?
Who prescribed the medication?
When was Baycol first prescribed to you?
For what length of time did you take the medication?
Were you monitored by the prescribing physician? (check one)
Weekly Once a year
Monthly Never
Every 6 months
Are you currently on any other medications?
YES NO
If yes, please list:
Were you on any other medication while you were on Baycol?
Gemfibrozil(Lopid) Immunosuppressive Drugs
Azole Anti-Fungals Erythromycin
HMG-CoA Inhibitors Nicotonic Acid
(other medications):
email address:





Setting the standard in toxic tort litigation for over a decade

180 Maiden Lane • New York, NY 10038
1 (800) 476–6070
e-mail: ClientRelations@weitzlux.com

Please know that you are not considered a client of our firm until your case has been accepted by us, and you have signed a formal “retainer agreement.”