Name Specialty Address Reason for Approx. Dates/Years of Visits MEDICAL BACKGROUND OF THE PERSON TREATED WITH TRT (“YOU”) Current Height: Current Weight: Do you currently suffer from any serious physical injuries, illnesses or disabilities other than those that you believe were caused by TRT? Yes _____ No _____ If yes, provide the information requested below: Injury, Illness or Disability Date of Onset Date of Diagnosis Physician Who Diagnosed You (Name and Address) For the period of time fifteen (15) years prior to your use of TRT up to the present, have you ever used tobacco (including cigarettes, cigars, pipes, and/or chewing tobacco/snuff)? Yes _____ No _____ If yes, provide the information requested for each type of tobacco ever used: Type(s) of tobacco used Dates of Use (approx.) Amount Used Per Day (approx.) Date Use Stopped Blank if Currently Use) For the period of time five (5) years prior to your treatment with TRT up to the present, did you drink alcohol? Yes _____ No _____ If yes, what was your approximate average alcohol consumption during that time: _____ approximately drinks per day, or _____ approximately drinks per week, or approximately drinks per month, or
Congenital heart abnormality or condition Congestive failure or cardiomyopathy Coronary artery disease or other heart disease Deep Vein Thrombosis (DVT) Enlarged heart/cardiomegaly attack (or myocardial infarction [MI]); silent MI Hypertension or high blood pressure; Pulmonary Embolism (PE) Seizure disorder or epilepsy Any Stroke: ischemic or hemorrhagic; hemorrhage; transient ischemic attack (TIA) Venous thromboembolism (VTE) If you answered “yes”, to question G, then provide the information requested below: Condition Health Care Provider Treatment Received Approx. Dates or Years of Treatment/Visits Are you are claiming that you suffered from a stroke, transient ischemic attacks, clots, venous thromboembolism, deep vein thrombosis, or a pulmonary embolism as a result of your treatment with TRT? Yes _____ No _____ Are you are you claiming that you suffered from a heart attack, myocardial infarction, or any other heart-related condition as a result of your treatment with TRT? Yes _____ No _____ If you answered “yes”, to questions I or J, then provide the information requested below with regard to all treatment received by you in the last ten (10) years for any of these
Identify the total period of time you were treated with TRT: Were there times when your TRT treatment was discontinued during that period? Yes _____ No _____ Don’t Recall _____ Complete the following chart with respect to each TRT medication to identify each product with which you were treated: Drug Name Prescribing Physician Pharmacy That Dispensed Approx Dates of Use How Often Administered or Applied If you were treated with TRT, but do not presently recall the name of the drug, provide the information requested below: Type: (Patch, Gel, Injection, Tablets, Pellets or Capsules) Dates of Use Prescribing or Dispensing Health Care Provider Pharmacy or store where purchased Date(s) of purchase Identify any other relevant information to support and/or identify how you obtained your TRT: __________________________________________________________________ If any gaps of time in your usage of any TRT product, please identify: _______________ Produce all records or other information that documents that you or someone on your behalf was dispensed prescriptions and/or samples of the TRT products used by you prior to the date of your alleged TRT-related injuries (this information may include, but is not limited to, pharmacy records, prescription records, personal notes, medical records and/or sworn statements from prescribing healthcare provider or any other healthcare providers). Did you ever receive any samples of TRT? Yes _____ No _____ Don’t recall _____ If yes, identify who gave you the sample, when you received it, the specific products included in the samples, and how many samples you received: whether you requested TRT from any Health Care Provider. Yes _____ No _____