Personal Health BEFORE you began taking Propulsid

* Had you ever been to a cardiologist before you were started on Propulsid? (Explain)

* Were you taking any medications for your heart prior to taking Propulsid? (Mark appropriate box)

Bumex (diuretic) Nitroglycerine Coumadin Diltiamem (calcium channel blocker) Lasix Tiazic (calcium channel blocker) Coreg (beta-blocker) Verapamil (calcium channel blocker) Topral (beta-blocker) Other Medication Other Medication Other Medication Other Medication

* Did you have any of the following before you were started on Propulsid?

Yes      No             Yes      No    Irregular heartbeat Low calcium Abnormal cardiogram Low potassium Heart disease Low magnesium Lung disease Persistent vomiting Kidney disease Acute dehydration Bulimia or anorexia Family history of heart disease Hypertension Congenital heart problem Diabetes Rheumatic fever High cholesterol Mitral valve prolapse

* Had you undergone any of the following procedures before you were started on Propulsid?

Yes      No    Date Findings Echocardiogram (EKG or EKC) Cardiac catheterization Cardiac ablation Cardiac defibrillator implantation Cardiac pacemaker implantation Coronary artery angioplasty Coronary artery bypass surgery

If you had any kind of significant health problem BEFORE taking Propulsid, please explain them here:

History of Propulsid Use

If you are married, and you were married to the same person when you took Rezulin, what is his or her name?

* In what state or states did you live when you were taking Propulsid?

* Name and address of doctor who prescribed Propulsid for you:

Name and address of any other doctor who prescribed Propulsid for you:

* During what period of time did you take Propulsid?   Starting Ending

*  What dosage instructions were you given for Propulsid? In other words, how many milligrams and how many times a day?

* Were you told not to drink grapefruit juice when you were taking Propulsid?   Yes  No

* Was Propulsid prescribed for you to treat the following:

Yes      No    Gastroesophageal Reflux Disease (GERD) Gastroparesis Hiatal hernia Severe constipation Night heartburn

* Did you take any of the following drugs during the time you were taking Propulsid?

Yes      No             Yes      No    Biaxin Betapace Zithromax Vascor Clarithromycin Crdioquin Erythromycin Quinidex Zagam Quiniglute Compazine Cordarone Phenergran Endep Ludomil Maprotiline Fen-Phen Amytriptyline Serzone Elavil Serlect Diflucan Crixivan Sporanox Norvir Nizoral Rezulin Duract Pronestyl

* Why did you stop taking Propulsid?

Personal Health AFTER you stopped taking Propulsid

* Have you experienced any of the following since you first took Propulsid?

Yes      No             Yes      No    Cardiac arrhythmia Cardiac arrest Cardiac dysrhythmia Heart attack Ventricular tachycardia Difficulty breathing Ventricular fibrillation Shortness of breath Torsades de pointes Dizziness QT prolongation Fast heartbeat Unusual weakness Irregular heartbeat Unexplained vomiting Electrolyte imbalance

* Have you ever gone to an Emergency Room or been admitted to a hospital for heart related problems? (Explain)

* Had you undergone any of the following procedures AFTER taking Propulsid?

Yes      No    Date Findings Echocardiogram (EKG or EKC) Cardiac catheterization Cardiac ablation Cardiac defibrillator implantation Cardiac pacemaker implantation Coronary artery angioplasty Coronary artery bypass surgery

Have you been diagnosed with any specific heart condition? (Indicate diagosis)

* Are you currently taking any medications for your heart? (Mark appropriate box)

Bumex (diuretic) Nitroglycerine Coumadin Diltiamem (calcium channel blocker) Lasix Tiazic (calcium channel blocker) Coreg (beta-blocker) Verapamil (calcium channel blocker) Topral (beta-blocker) Other Medication Other Medication Other Medication Other Medication

If you believe you have had, or might have had, any kind of bad reaction to Propulsid, please explain: