Rezulin 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 Rezulin 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 • 615 Franklin Turnpike • Ridgewood NJ 07450-1929
or fax toll-free to: 1-877-926-9210

Rezulin Claim History Questionnaire for a Deceased Person

* Decedent's Name:
* Date of Decedent's Death:
* Decedent's Age at Death:
* Decedent's Birthdate:
* Decedent's Social Security Number:
* 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 Rezulin

* Date decedent was diagnosed as Diabetic:

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

* Name and address of doctor who diagnosed diabetes:

* What medications was decedent taking for diabetes before Rezulin?

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

   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 Rezulin?

   Yes     No

Date of Diagnosis:

Treatment:

Physician who Diagnosed:

Address:

* Did decedent ever receive a blood transfusion before he or she started on Rezulin?

   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, other than diabetes, BEFORE taking Rezulin, please explain them here:

History of Rezulin Use

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

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

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

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

* During what period of time did the decedent take Rezulin?

Starting:

Ending:

What was the dosage of Rezulin prescribed?

* What other medications did decedent take while taking Rezulin?

Personal Health AFTER Taking Rezulin

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

  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 Rezulin, please explain:

©2000 Joseph R. Santoli, Esq.
615 Franklin Turnpike
Ridgewood NJ 07450-1929
Toll-Free (877) 926-9202 • Phone (201) 444-2888 • Toll-Free Fax (877) 926-9210