Rezulin Questionnaire

If you are interested in exploring your legal options for a potential claim against the manufacturer of Rezulin, 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 you spouse to be included on the claim)
Best time to call:


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

A) Have you had a liver transplant?
YES NO
If yes, when?
Medical Facility?
B) Have you been diagnosed with liver damage?
YES NO
If yes, when?
Diagnosis:
C) Have you had a liver function test since taking the medication?
YES NO
If yes, when?
Results:
D) Do you have any of the following symptoms of liver disfunction? (check all that apply)
Nausea Jaundice
Vomiting Dark Urine
Abdominal Pain Clay-colored stools
Loss of Appetite Unusual fatigue
E) Have you experienced any symptoms of heart failure? (check all that apply)
Enlarged heart High blood pressure
Edema (swelling) Jaundice
Other:
When were you first diagnosed with Type II diabetes?
What diabetes medication(s) were you prescribed?
Rezulin Actos
Avandia
Other:
Who prescribed the medication(s)?
When was each drug prescribed to you?
Month:
Date:
Year:
For what length of time did you take the medication?
Were you given a liver function test before being given a prescription for the medication(s)?
YES NO
Were you informed of any possible risks associated with the use of the medication(s)?
YES NO
If yes, what risks?
How often were you monitored by the prescribing physician?
Weekly Once a year
Monthly Never
Every 6 months
Height and weight before taking the medication(s)?
Height:
Weight:
Weight after taking the medication(s)?
Current weight?
While on Rezulin, did you take any other medications?
YES NO
If yes, please list:
Are you currently on any other medications?
YES NO
If yes, please list:
Have you taken any prior legal action against the makers of Rezulin?
YES NO
email address:





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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.”