Kip Petroff & Associates - Dedicated to representing those injured by the weight loss drugs Fen Phen, Pondimin and Redux

Petroff & Associates
3838 Oak Lawn Ave.
Suite 1124
Dallas, Texas 75219

214-526-5300
214-526-5354 (fax)

E-Mail: kpetroff@petroffassociates.com

Fen Phen Questionnaire

PART ONE: INSTRUCTIONS
The following questions are designed to allow us to determine if you, or your loved one, has a potential diet drug “High Level Claim”. All of these questions are important. We realize that you may not know the answers to all questions. Please answer all questions to the best of your ability and we will let you know if we need additional information. You may submit this Questionnaire in one of two ways: Online: Please fill out the form below and hit the "Send" button at the bottom. Please note that you must enter an e-mail address for the form to send. By Mail: If you prefer, you may print out a pdf version of this questionnaire and mail it to: Petroff & Associates 3838 Oak Lawn Ave. Suite 1124, Dallas, TX 75219 Our Response Time: We try to respond promptly to all Questionnaires from prospective clients, but we sometimes cannot meet that goal. Please make sure to follow up with us if you haven’t heard back from us within three business days of submitting this Questionnaire online, or within two weeks of submitting this Questionnaire by postal mail.
PART TWO: PERSONAL BACKGROUND INFORMATION
Name: Required*
E-mail Address: Required*
Confirm E-mail Address:
Mailing Address:
City:
State:
Zip Code:
Phone:
Date of Birth:
How would you prefer that we contact you?	E-mail Phone Mail Any of the above

PART THREE: CLAIMS INFORMATION
1. Did you register with the AHP Settlement Trust by filing a "Blue" Form or a "Green" Form on or before 5/3/03?		Yes No Don't Know Not Answered
2. Did you have an echocardiogram performed before 1/3/03?		Yes No Don't Know Not Answered
2a. If you had an echocardiogram performed before 1/3/03, do you have a copy of the written report from your doctor?		Yes No Don't Know Not Answered
2b. If you had an echocardiogram performed before 1/3/03, do you have a copy of the videotape or disc of the echocardiogram?		Yes No Don't Know Not Answered
3. Did you take either Pondimin or Redux?		Yes No Don't Know Not Answered
3a. If you took either Pondimin or Redux, do you have written proof or a written record that proves you took either one of these diet drugs?		Yes No Don't Know Not Answered
4. Have you received any amount of money from either the AHP Settlement Trust or from the Seventh Amendment Fund Administrator?		Yes No Don't Know Not Answered
5. Were you assigned a Diet Drug Recipient (DDR) Number?		Yes No Don't Know Not Answered
6. Were you represented by an attorney on your Diet Drug Claim?		Yes No Don't Know Not Answered
6a. If you were represented by an attorney on your Diet Drug Claim, please provide the name and address of your attorney.
type answer to 6a here
6b. If you were represented by an attorney on your Diet Drug Claim, when was the last time that you had any contact with your attorney?
type answer to 6b here
6c. If you were represented by an attorney on your Diet Drug Claim, did your attorney send you a withdrawal or disengagement letter?		Yes No Don't Know Not Answered
6d. If your attorney sent you a withdrawal letter or disengagement letter, please state the date of that letter.
type answer to 6d here
7. If you are answering this questionnaire on behalf of a person who is deceased, did this person die suddenly as a result of a heart condition?		Yes No Don't Know Not Answered
8. If you are answering this questionnaire on behalf of a person who is deceased, was an autopsy performed?		Yes No Don't Know Not Answered
PART FOUR: MEDICAL HISTORY QUESTIONS
9. Have you been diagnosed with bacterial endocarditis?		Yes No Don't Know Not Answered
10. Have you had episodes of chronic or recurrent atrial fibrillation?		Yes No Don't Know Not Answered
11. Have you had a procedure called an ablation?		Yes No Don't Know Not Answered
12. Are you taking Coumadin?		Yes No Not Answered
13. Have you had a stroke that was due to a blood clot?		Yes No Don't Know Not Answered
13a. If you had a stroke that was due to a blood clot, did the blood clot originate in your heart?		Yes No Don't Know Not Answered
13b. If you had a stroke that was due to a blood clot, then please list any problems that you are having with daily activities, such as feeding, swallowing, grooming, dressing, bathing, continence, toileting, mobility, using the telephone, handling money, shopping, using transportation, maintaining a household, working, participating in leisure activities, etc.
type answer to 13b here
13c. Have any of the problems that you listed in response to 13b that lasted for a period of six (6) months or more?		Yes No Don't Know Not Answered
14. Have you had a blood clot that resulted in kidney failure and dialysis, abdominal surgery, or amputation of one of your arms or legs?		Yes No Not Answered
15. Have you had any episodes of ventricular fibrillation or ventricular tachycardia?		Yes No Don't Know Not Answered
16. Have you ever been in a coma?		Yes No Not Answered
17. Have your doctors or paramedics used an external defibrillator on your heart?		Yes No Don't Know Not Answered
18. Have your doctors inserted an internal defibrillator?		Yes No Don't Know Not Answered
19. Have you had a coronary artery bypass?		Yes No Not Answered
20. If you had a coronary artery bypass, did the surgeon also repair or replace your mitral heart valve or your aortic heart valve during this procedure?		Yes No Don't Know Not Answered
21. Have you had surgery to repair or replace your mitral heart valve or your aortic heart valve?		Yes No Not Answered
21a. If you had surgery, what was the date of the surgery?
type answer to 21a here
22. Have you had an echocardiogram that showed an ejection fraction that was less than 35%?		Yes No Don't Know Not Answered
22a. If you had an echocardiogram that showed an ejection fraction that was less than 35%, has your cardiologist recommended that you undergo heart valve surgery?		Yes No Don't Know Not Answered
23. Have you had a heart transplant?		Yes No Not Answered
24. Has a medical doctor diagnosed you with Pulmonary Hypertension or Primary Pulmonary Hypertension?		Yes No Don't Know Not Answered
PART FIVE: HOSPITALIZATIONS If you answered "Yes" to any of these questions that are set forth above and you were hospitalized for the event or condition in question, please set forth the name and address of the hospital and the dates that you were hospitalized for the event or condition in question. If you have had no hospitalizations in relation to the questions above, please leave the default text in the boxes and skip this section.
1:
Event or Condition:	type answer for event 1 here
Name & Address of Hospital:	type answer for event 1 here
Date of Hospitalization:	type answer for event 1 here
2:
Event or Condition:	type answer for event 2 here
Name & Address of Hospital:	type answer for event 2 here
Date of Hospitalization:	type answer for event 2 here
3:
Event or Condition:	type answer for event 3 here
Name & Address of Hospital:	type answer for event 3 here
Date of Hospitalization:	type answer for event 3 here
4:
Event or Condition:	type answer for event 4 here
Name & Address of Hospital:	type answer for event 4 here
Date of Hospitalization:	type answer for event 4 here
5:
Event or Condition:	type answer for event 5 here
Name & Address of Hospital:	type answer for event 5 here
Date of Hospitalization:	type answer for event 5 here
(To list more information, please use the text box below).
PART SIX: CONCLUSION COMMENTS/QUESTIONS: WE REALIZE THAT YOU MAY WANT TO TELL US SOMETHING ABOUT YOUR CLAIM THAT MAY NOT HAVE BEEN ASKED ABOVE. YOU CAN USE THE SPACE BELOW FOR THAT PURPOSE. WE ALSO REALIZE THAT YOU MAY NOT KNOW THE ANSWERS TO ALL QUESTIONS. JUST GIVE US THE BEST ANSWERS YOU CAN. WE WILL LET YOU KNOW IF WE NEED ADDITIONAL INFORMATION. THANK YOU FOR YOUR INTEREST IN OUR FIRM POSSIBLY REPRESENTING YOU IN YOUR POTENTIAL HIGH LEVEL CLAIM.

Please type your comments and/or questions below:

*Please ensure that you have filled in the name and e-mail address fields at the top (marked “Required”). Your e-mail address is required for the form to send.

Petroff & Associates
Attorneys At Law
3838 Oak Lawn Avenue, Suite 1124, Dallas, Texas 75219
214-526-5300 ~ 214-526-5354 (fax)

Disclaimer: The information in this web site has been prepared by Petroff & Associates, Attorneys at Law, for informational purposes only and is not to be intended as legal advice. Viewing this site, receipt of information contained on the web site or the transmission of information does not constitute an attorney-client relationship. Persons receiving the information via this web site should not act upon the information without seeking professional legal advice. Kip Petroff is board certified in Personal Injury and Civil Trial Law by the Texas Board Of Legal Specialization. Stan Hudson is board certified in Personal Injury Trial Law by the Texas Board Of Legal Specialization. These lawyers are responsible for the content of these advertisements.