* During what period of time did you take Trovan?   Starting Ending
* In what state or states did you live when you were taking Trovan?
* Name and address of doctor who prescribed Trovan for you:
Name and address of any other doctor who prescribed Trovan for you:
* Condition(s) being treated:
* Your weight:
* How frequently were you monitored by the physician who prescribed Trovan?
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?
If you took the medication during more than two periods of time, please provide the additional dates that you started and stopped:
* During or since your use of Trovan, have you experienced, suspected or been diagnosed with any of the following conditions:
Yes      No    High Blood Pressure Chest Pain Liver Damage Liver Failure Liver Abnormalities Liver Releted Injuries Liver Toxicity Need for Liver Transplant Unexplained Change in Health
* Has Liver Function Testing been performed? Yes       No
If you answered YES to the above question, please enter either the date the test was performed or the date of your knowledge of the results:
What were the results of the testing?
What other medication have you taken in the past 5 years?
If there is something you wish to add, do it here: