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    • Avandia Case Evaluation Form

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    CASE INFORMATION
    Why Was Avandia Prescribed?: *
    What Dosage, in Milligrams?:
    How Frequently Was Avandia Taken?:
    Date Patient Began Taking Avandia:

    Stopped Taking Avandia:

    What Symptoms Were Experienced?: *
    Heart Attack
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    Heart Failure

    		 Death
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    PPH
    If "Other", Please Describe:
    How Long Was it From the Last Dose to the Problems Appearing?:
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        More Than 3 Days Don't Know
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YOUR CONTACT INFORMATION
First Name: *
Last Name: *
E-mail Address: *
Address:
City:
State: *
Zipcode:
Phone: -- xtn

CASE INFORMATION
Why Was Avandia Prescribed?: *
What Dosage, in Milligrams?:
How Frequently Was Avandia Taken?:
Date Patient Began Taking Avandia:

Stopped Taking Avandia:

What Symptoms Were Experienced?: *
Heart Attack
Stroke
Heart Failure

 Death
Other
PPH
If "Other", Please Describe:
How Long Was it From the Last Dose to the Problems Appearing?:
    Within 1 Day 2 Days 3 Days
    More Than 3 Days Don't Know
Questions/Comments:
This form is secure and encrypted. More information about secure forms and your privacy here.