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:
 
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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?
Complaint:

 

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)
5.Other
 
If "Other" please enter the name of the medication.
Name of Drug  
When Started and Ended


* DATE HORMONAL REPLACEMENT DRUG ENDED 


During what period of time was HRT prescribed?
Start End

Why was HRT prescribed?
 

Other medications while taking HRT:


Comments:


DISEASE QUESTIONS:
 
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:
Disclaimers:

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

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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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