Ortho Evra Patch Cases
Ortho Evra Patch CasesThe following Ortho Evra Patch Cases warrant investigation:
Our criteria is basically DVT, PE, CVA or MI suffered while on the patch, or shortly thereafter (I.e. during the week that the patch is not warn). In certain circumstances we are taking cases where there is a longer latency if there had been recorded complaints of related symptoms.
Please feel free to use this intake if you think it will help you.
If you have any questions don't hesitate to ask.
ORTHO EVRA QUESTIONNAIREDate: Name: Address: City: State: Zip: Age: Birth Date: Email: _____Home Phone: Work Phone: Cell Phone: Fax: Best time to contact you: Alternate Contact: Have you suffered: Date/State of Occurrence: Stroke (CVA): Yes No ____ Pulmonary Embolism (PE): Yes No Heart Attack (MI): Yes No Deep Vein Thrombosis (DVT): Yes No Primary Pulmonary Hypertension (PPH): Yes No Blood Clots (where?): Yes No Hospitalization (for above/how long?): Yes No Are you a smoker? Yes No Have you quit smoking? Yes No Describe smoking history (how much/how long): ORTHO EVRA HISTORYWhen did you begin to use Ortho Evra? When did you stop using Ortho Evra? What were the adverse symptoms? When did you first notice adverse symptoms? Current medications (Coumadin/Warfarin, Plavix, Aspirin, etc.): Other medications: Notes: