Your Case

*Required Fields

Defendant:
(who caused the harm?)

Zyprexa

*Title:
(describe the nature of your complaint in one short sentence)

What is the best way to contact you? (time, phone number, etc)

Additional contact information:

Date of Birth: (mm dd yy)

Whom are you inquiring on behalf of? (self, minor, other)

If you are NOT inquiring on your own behalf, what is your relationship?

Is the person deceased?

Yes No

If deceased, what is the cause of death as stated on the death certificate?

Date of Death:

Was there an autopsy performed?

Yes No

During what period of time was Zyprexa prescribed? Start date:

End date:

For what diagnoses or condition was Zyprexa prescribed?

List names/addresses of any doctors who prescribed Zyprexa:

Was diabetes diagnosed before Zyprexa?

Yes No

Was diabetes diagnosed after Zyprexa?

Yes No

Was Hyperglycemia diagnosed before Zyprexa?

Yes No

Was Hyperglycemia diagnosed after Zyprexa?

Yes No

Was Pancreatitis diagnosed before Zyprexa?

Yes No

Was Pancreatitis diagnosed after Zyprexa?

Yes No

Other information:

Is there a history of diabetes in your family?

Yes No

If yes who else has diabetes:

Parents?

Yes No

Grandparents?

Yes No

Siblings?

Yes No

Weight:

Height:

County of residence:

Your Information

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* First name:

* Last name:

* Email address:

* Confirm Email address:

* Day time phone:

Evening phone:

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Fax:

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