Personal Health BEFORE you began taking Zithromax®
* Date diagnosed with infection:
*  During what period of time did you take Zithromax®?   Starting Ending
* Name and address of doctor who diagnosed the infection:
* What medications were you taking for infection before Zithromax®?
* How would you rate your health status prior to your exposure to the Zithromax®:
Excellent        Good        Fair        Poor
* Were you ever diagnosed with Hepatitis before you started on Zithromax®?
Yes     No
Type of Hepatitis: Date of Diagnosis: Treatment: Physician who Diagnosed: Address:
* Were you ever diagnosed with Cirrhosis before you started on Zithromax®?
Yes     No
Date of Diagnosis: Treatment: Physician who Diagnosed: Address:
* Did you ever receive a blood transfusion before you started on Zithromax®?
Yes     No
If Yes:
Date Type ID# Where Given By Whom Source
* Please check appropriate boxes:
Yes      No Intravenous drug use Hemophilia HIV/AIDS Smoke Cigarettes
* Describe your alcohol intake:
Heavy        Moderate        Light        None
If you had any kind of significant health problem, BEFORE taking Zithromax®, please explain them here:
History of Zithromax® Use
If you are married, and you were married to the same person when you took Zithromax®, what is his or her name?
* In what state or states did you live when you were taking Zithromax®?
* Name and address of doctor who prescribed Zithromax® for you:
Name and address of any other doctor who prescribed Zithromax® for you:
Name and address of any other doctor who prescribed Zithromax® for you:
What did the physician tell you, if anything, about the risks of taking Zithromax®?
* During what period of time did you take Zithromax®?
Starting:
Ending:
What was the dosage of Zithromax® prescribed?
If you took this medication during more than one period, i.e., stopped for some time and started again, please complete the following:
The date you stopped:
The date you started again:
The date you stopped again:
Why did you stop and start again?
* What other medications were you taking when you were taking Zithromax®?
* How frequently did the physician who prescribed Zithromax® for you monitor you?
* Did the physician monitor your liver with blood tests? If so, how frequently and what were the results?
Personal Health AFTER Taking Zithromax®
* Have you experienced, suspected or been diagnosed with any of the following since you first took Zithromax®?
Yes      No    Hepatitis Cirrhosis Liver Failure Liver Abnormalities Liver Releted Injuries Liver Toxicity Need for Liver Transplant Unexplained Change in Health
If you answered yes to any of the above, what is the current nature of treatment?
Name and address of doctor currently treating liver condition:
If you believe you have had, or might have had, any kind of bad reaction to Zithromax®, please explain: