HRT (Hormone Replacement Therapy) Survey

Please fill out the form below to have your case reviewed. Provide as much information as possible to speed the processing of your inquiry
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There is no charge for this evaluation.
Contact Information:
*Title: *First Name: MI: *Last Name:
*E-mail Address:
*Retype E-mail:
Home Phone:
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Mobile Phone: - -
Work Phone: - - ext.
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Street Address:
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Please provide the best place, time and method for contacting you.
Additional Contact Information:
Use this area to add country codes, foreign addresses, special instructions, etc.
Injured Person Information:
Date of Birth:
Whom are you inquiring on behalf of?
If you are NOT inquiring on your own behalf, what is your relationship?


Case Information:
Which hormonal replacement drug were you taking?
1.Premarin (estrogen only)
2.Provera (progestin only)
3.Prempro (estrogen + progestin)
4.Premphase (estrogen + progestin)
If "Other" please enter the name of the medication.
Name of Drug  
When Started and Ended


During what period of time was HRT prescribed?
Start End

Why was HRT prescribed?

Other medications while taking HRT:


Breast Cancer          Yes No
1. Lobular Yes No
2. Ductal  Yes No
If ductal were hormone receptors positive for estrogen: Yes No
If ductal were hormone receptors positive for progesterone Yes No
Date of Diagnosis
Lupus    Yes     No
Date of Diagnosis
Heart Attack      Yes   No
Date of Diagnosis
Stroke     Yes    No
Date that Stroke Occured
Pulmonary Embolism     Yes    No
Date of Occurance
Ovarian Cancer    Yes   No
Date of Diagnosis

Other Diagnosis

If yes, please describe any adverse effects or side effects that resulted from HRT.

Other Information:

Yes No - I agree that this matter may be referred to an attorney who may contact me.

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By Clicking the appropriate box below, I agree that:

The above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this questionnaire. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above questionnaire is general information and I will not be charged for the response to this e-mail questionnaire. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require legal advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.


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