First Name MI  

Last Name

Social Security No.  

Driver's License No. State D.O.B.

Spouse's First Name MI Last Name

Social Security No.

Driver's License No. State D.O.B.

Residence Address

City/State Zip

County

Your Home Phone

Business Phone

Spouse's Business Phone, if different:

Fax Phone Email Address

Height Weight

Are you covered by medical insurance?

Policy No.

Name of Provider

Have you taken any of the drugs listed below, either singularly or in combination with each other? (Please check)

 List the names of the physicians that prescribed these drugs to you:

Have you noticed any of the following symptoms after you began to take the above drugs?  (Please check)

Shortness of breath                                       Chest Pains

Shortness of breath upon exertion                   Palpitation or pounding heart

Decreased tolerance to exercise                    High blood pressure

Irregular heart beat                                       Swelling in the feet and ankles

Other (Explain):

Have you ever been treated for any of the above?  Yes   No

What was the diagnosis as to each problem? (fill in answer in box below)

List your primary care physician (s) as to each problem:

Have you been diagnosed with any heart or lung ailments?  Yes  No

If so, describe by whom, when and what the nature of the problem was:

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Until  P & P agrees to accept this case, and a written contract is executed by both the undersigned and P & P, P & P can and will take no action to protect our rights.  We also request P & P, or any other law firm working in conjunction with P & P, to review this material and to call/contact us to discuss this matter further.

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Date:             Date: