Zithromax® Claim History Questionnaire for a Deceased Person

This questionnaire is intended to provide the basic information necessary to evaluate your claim for compensation arising from the taking of Zithromax® by someone now deceased. Please complete it to the best of your ability with as much detail as possible. Any information you submit will be kept strictly confidential.

Please complete the form and click the "submit" button at the end to send the information to us electronically. Note that information in fields marked with an asterisk must be completed in order for this form to be processed.

You may also complete the form, print out and mail to:
Joseph Santoli • 340 Devon Court
Ridgewood NJ 07450-1810
Toll-Free 1-800-279-6996

Zithromax® Claim History Questionnaire for a Deceased Person

* Decedent's Name:
* Date of Decedent's Death:
* Decedent's Age at Death:
* Decedent's Birthdate:
* Your Name:
* Your Relationship to Decedent:
* Your Telephone Number:
* Your Mailing Address:


* Your E-mail Address:
* Do you have Power of Attorney over decedent's estate?
Yes No

Health of Decedent BEFORE he or she began taking Zithromax®

* Date decedent was diagnosed with infection:

* During what period of time did the decedent take Zithromax®?   Starting Ending

* Name and address of doctor who diagnosed the infection:

* What medications was decedent taking for infection before Zithromax®?

* Was decedent ever diagnosed with Hepatitis before he or she started on Zithromax®?

   Yes     No

Type of Hepatitis:

Date of Diagnosis:

Treatment:

Physician who Diagnosed:

Address:

* Was decedent ever diagnosed with Cirrhosis before he or she started on Zithromax®?

   Yes     No

Date of Diagnosis:

Treatment:

Physician who Diagnosed:

Address:

* Did decedent ever receive a blood transfusion before he or she 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 decedent's alcohol intake:

Heavy       Moderate       Light       None

If decedent had any kind of significant health problem, BEFORE taking Zithromax®, please explain them here:

History of Zithromax® Use

* In what state or states did the decedent live when he or she was taking Zithromax®?

* Name and address of doctor who prescribed Zithromax® for the decedent:

Name and address of any other doctor who prescribed Zithromax® for the decedent:

Name and address of any other doctor who prescribed Zithromax® for the decedent:

* During what period of time did the decedent take Zithromax®?

Starting:

Ending:

What was the dosage of Zithromax® prescribed?

* What other medications did decedent take while taking Zithromax®?

Personal Health AFTER Taking Zithromax®

* Did the decedent experience any of the following after he or she started on Zithromax®?

  Yes      No

Hepatitis

Cirrhosis

Liver Failure

Liver Abnormalities

Liver Releted Injuries

Liver Toxicity

Need for Liver Transplant

Unexplained Change in Health

* What was the Cause of Death listed on the decedent's Death Certificate?



* Was an autopsy performed on the decedent?

    Yes     No

If you believe the decedent had any kind of bad reaction to Zithromax®, please explain:

�2003 Joseph R. Santoli, Esq.
340 Devon Court
Ridgewood NJ 07450-1810
Toll-Free 1-800-279-6996