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In re Yasmin and Yaz Marketing

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF ILLINOIS


March 3, 2010

IN RE YASMIN AND YAZ (DROSPIRENONE) MARKETING, SALES PRACTICES AND RELEVANT PRODUCTS LIABILITY LITIGATION

EXHIBIT-1

(CMO No. 12)

MDL No. 2100

PLAINTIFF FACT SHEET

Please provide the following information for each individual on whose behalf a claim is being made. If you are completing this Plaintiff Fact Sheet in a representative capacity, please respond to the remaining questions with respect to the person who used Yaz® and/or Yasmin® and/or Ocella®. Whether completing this fact sheet for yourself or for someone else, please assume that "You" means the Yaz® and/or Yasmin® and/or Ocella® user.

In filling out this form, please use the following definitions: (1) "health care provider" means any hospital, clinic, medical center, physician's office, infirmary, medical or diagnostic laboratory, or other facility that provides medical, dietary, psychiatric or psychological care or advice, and any pharmacy, weight loss center, x-ray department, laboratory, physical therapist or physical therapy department, rehabilitation specialist, physician, psychiatrist, osteopath, homeopath, chiropractor, psychologist, nutritionist, dietician, or other persons or entities involved in the evaluation, diagnosis, care and/or treatment of you; (2) "document" means any writing or record of every type that is in your possession, including but not limited to written documents, documents in electronic format, cassettes, videotapes, photographs, charts, computer discs or tapes, and x-rays, drawings, graphs, phone-records, non-identical copies and other data compilations from which information can be obtained and translated, if necessary, by the respondent through electronic devices into reasonably usable form.

You may attach as many sheets of paper as necessary to fully answer these questions.

I.CASE INFORMATION

1. Name of person completing this form: _________________________________________

Yaz®, Yasmin® Ocella® Plaintiff Fact Sheet

2. Please state the following for the civil action that you filed:

a. Case caption: _______________________________________________________

b. Docket Number: ____________________________________________________

c. Court in which action was originally filed: ________________________________

d. Name, address, telephone number, fax number and email address of principal attorney representing you:

Name: ____________________________________________________________

Firm: _____________________________________________________________

Address: __________________________________________________________

Telephone Number: _________________ Fax Number:_____________________

E-mail Address: ____________________________________________________

3. If you are completing this Plaintiff Fact Sheet in a representative capacity (e.g., on behalf of the estate of a deceased person or a minor), please complete the following:

a. Your name:

b. Current Address: ____________________________________________________

c. In what capacity are you representing the individual or estate: ________________

d. If you were appointed as a representative by a court, state the:

Court Which Appointed You: __________________________________________

Date of Appointment: ________________________________________________

e. What is your relationship to the individual you represent: ____________________

THE REST OF THIS PLAINTIFF FACT SHEET REQUESTS INFORMATION ABOUT THE PERSON WHO USED YAZ® AND/OR YASMIN® AND/OR OCELLA®

II.PERSONAL INFORMATION

1. Name: __________________________________________________________________

2. Maiden or other names used and dates you used those names: ______________________

________________________________________________________________________

3. Current Address and Date when you began living at this address: ____________________

________________________________________________________________________

4. Identify each address at which you have resided during the last ten (10) years, and the dates you resided at each one.

Address Dates of Residence

5. Social Security Number: ____________________________________________________

6. Date and Place of Birth: ____________________________________________________

7. Current Marital Status: _____________________________________________________

8. If married, has your spouse filed a loss of consortium or other claim?

Yes ________ No _________

9. Occupation of current spouse: _______________________________________________

10. Name(s) of current and former spouse(s), date(s) of marriage(s) and dates the marriage(s) were terminated, if applicable, and the nature of the termination (e.g., death, divorce):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

11. If you have children, please identify each child's name, address and date of birth.

Child's Name and Address Date of Birth

12. Identify all schools you attended, starting with high school:

Name of School Address and Dates of Degree Major or

Telephone Number attendance Awarded Primary Field

13. Are you currently employed? Yes______ No______

If "Yes", please identify your current employer and position there: __________________

________________________________________________________________________

a. Did you ever leave this job for a medical reason? Yes______ No______

If "Yes", describe why you left: ________________________________________

14. Have you ever served in any branch of the military? Yes ________ No ________

a. Branch and dates of service: ___________________________________________

If "Yes", were you ever were discharged for any reason relating to your medical, physical or psychiatric condition?

Yes ______ No _______

If "Yes", state what that condition was: __________________________________

b. Have you ever been rejected from military service for any reason relating to your medical, physical, or psychiatric condition?

Yes ______ No ________

If "Yes", state what that condition was: __________________________________

________________________________________________________________________

15. Identify each insurance carrier with whom you had health insurance coverage at any time beginning ten (l0) years prior to using Yaz® and/or Yasmin® and/or Ocella® (or the age of 13, whichever is later) up to the present, and please include all private insurance and public assistance if applicable:

Name of Insurance Policy Number Name of Policy Approx. Dates of

Company Holder/Insured (if Coverage different than you)

16. Have you applied for workers' compensation, social security, or state or federal disability benefits within the past ten (l0) years?

Yes ________ No _________

If "Yes", then as to each application, separately state:

a. Date (or year) of application: __________________________________________

b. Type of benefits: ____________________________________________________

c. Nature of claimed injury/disability: _____________________________________

d. Period of disability: __________________________________________________

e. Amount awarded: ___________________________________________________

f. Basis of your claim: _________________________________________________

g. Was claim denied? Yes______ No______

h. To what agency or company did you submit your application:

i. Claim/docket number, if applicable: _____________________________________

17. Have you ever been denied life insurance for reasons relating to your health?

Yes______ No______ I don't know______

If "Yes", please state when the denial occurred, the name of the life insurance company, and the company's reason for denial:

________________________________________________________________________

________________________________________________________________________

18. Have you ever filed a lawsuit other than the present suit, relating to any bodily injury within the past ten (10) years?

Yes______ No______

If "Yes", please explain the nature of the case, where it was filed, and identify your lawyer:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

19. In the last 10 years, have you been convicted of or pled guilty to any felony and/or have you been convicted of or pled guilty to any crime that involved an alleged act of dishonesty or providing a false statement?

Yes______ No______

If "Yes", please state the charge to which you pled guilty to or were convicted, as well as the court where the action was-pending: _____________

________________________________________________________________________

III.HEALTH CARE PROVIDERS AND PHARMACIES

1. Identify each doctor or other health care provider who you have seen for medical care and treatment in the past ten (10) years:

Doctor or Health Doctor or Address Reason for Approx. care Provider's Health care Visit Dates/Years

Name Provider's of Visits

Specialty

2. Identify each hospital, clinic, or health care facility where you were hospitalized (inpatient, out-patient, or emergency room visit) in the past ten (10) years:

3. Name Address and Admission Reason for Admission

Telephone Number Date(s) Approx dates/years of visits

4. Identify each pharmacy that has dispensed medication to you in the past ten (10) years:

5. Name of Pharmacy Address and Telephone Name of medication Approx.

Number of Pharmacy dispensed Dates/Years

You Used

Pharmacy

IV. MEDICAL BACKGROUND

1. Current Height:___________

2. Current Weight:___________

3. Approximate weight immediately before using Yaz® and/or Yasmin® and/or Ocella®:___________

4. Approximate weight at the time of your injury:__________

5. Approximate date and age of your first menstrual period:__________

6. Tobacco Use History: For the three (3) year period prior to your use of Yaz® and/or Yasmin® and/or Ocella® up to the present Check the answer and fill in the blanks applicable to your history of tobacco use, including cigarettes, cigars, pipes, and/or chewing tobacco/ snuff.

7. ___ I have never used tobacco.

8. ___ I used tobacco in three year period prior to my use of Yaz® and/or Yasmin® and/or Ocella®

9. Type(s) of tobacco used (cigarettes, cigars, pipes, smokeless tobacco, snuff)_______________________________

10. Approximate Date tobacco use started: ___________________

11. Approximate Amount used: ____________________________

12. ___ I currently use tobacco

13. Type(s) of tobacco used (cigarettes, cigars, pipes, smokeless tobacco,

14. snuff)____________________________________________________

15. Approximate Date tobacco use started: ___________________________

16. Approximate Amount currently using: on average ___ per day for __ years

17. ___ I have used different amounts of tobacco at different times (please identify type(s) of tobacco used and dates of use below).

18. _______________________________________________________________

19. _______________________________________________________________

20. Alcohol Consumption: For the one (1) year period prior to your use of Yaz® and/or Yasmin® and/or Ocella® up to the present, did you drink alcohol (beer, wine, etc.)?

21. Yes _____ No _____

22. If "Yes", fill in the appropriate blank with the number of drinks that best represents your approximate average alcohol consumption during that time:

23. _______drinks per week, or

24. _______drinks per month; or

25. _______drinks per year; or

26. Other (describe): _________________________

27. Caffeine Consumption: For the one (1) year period prior to your use of Yaz® and/or Yasmin® and/or Ocella® up to the present, did you consume caffeinated beverages (e.g., coffee, tea, soda):

28. Yes _____ No _____

29. (a) If "Yes", fill in the appropriate blank with the number of drinks that best represents your approximate average alcohol consumption during that time:

30. _______drinks per week, or

31. _______drinks per month; or

32. _______drinks per year; or

33. Other (describe): _________________________

34. (b) State the type of caffeinated beverages consumed (e.g., coffee, tea, soda):

35. __________________________________________________________________ __

36. ____________________________________________________________________

37. State whether in the 30 day period prior to the onset of the injuries for which recovery is sought in this action, you engaged in any prolonged travel (meaning six hours or longer), such as sitting in an airplane or a long car trip, and set forth the date of such travel, and provide a description of such prolonged travel, including date(s) and method(s) of travel:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

38. Have you ever been diagnosed with or sought treatment for any of the following conditions? Please select "Yes", "No" or "Unknown" for each condition.

(a) For each condition for which you answer "Yes", please provide the additional information requested in subpart (b):

Condition Yes No Unknown

1. Abnormal genital bleeding

2. Abnormality of blood vessels or circulatory system

3. Acne (within one year of use of Yaz®/Yasmin®/Ocella®)

4. Adrenal insufficiency

5. Alcoholism

6. Allergy, such as hay fever, asthma, eczema, hives, sensitivity to drugs and other substances

7. An abnormal physical condition symptomatic of any disease such as edema of the extremities, pain in the extremities, prolonged (longer than 1 week) subnormal or elevated temperature, recurring headaches, jaundice

8. Aneurysm

9. Angina or chest pain

10. Anorexia or bulimia

11. Any blood clotting disorder

12. Arteriovenous malformation (AVM)

13. Autoimmune disease or condition such as lupus, rheumatoid arthritis, psoriasis, scleroderma, or mixed-connective tissue disorder

14. Bleeding disorder

15. Blood clots or thrombosis

Condition Yes No Unknown

16. Blood disorder or dyscrasia

17. Brain tumors

18. Cancer - Breast

19. Cancer - Cervical

20. Cancer - Endometrial

21. Cancer - Other form of Cancer

22. Cerebrovascular disease or condition

23. Coronary artery disease or other heart disease

24. Cystitis

25. Deep Vein Thrombosis (DVT)

26. Diabetes

27. Ectopic Pregnancy

28. Elevated Cholesterol

29. Gastrointestinal disease such as gallbladder disease, colitis, intestinal obstruction, liver dysfunction

30. Glandular disease, such as malfunction of the pancreas, parathyroid, thyroid, adrenal, or pituitary

31. Gout

32. Heart attack

33. Heart valve disease or abnormality

34. Hepatic dysfunction or active liver disease

35. Hypercoagulable conditions (e.g., conditions, whether genetic or acquired, in which your blood clots too much)

36. Hypertension or high blood pressure

37. Hypotension

38. Increased C-reactive protein (CRP) levels

39. Infectious disease, such as tuberculosis, pneumonia, rheumatic fever, syphilis, gonorrhea, typhoid fever, encephalitis, poliomyelitis, malaria or hepatitis

40. Irregular heart beat, atrial fibrillation, arrhythmia, heart palpitations, tachycardia (rapid heart beat), bradycardia (slow heart beat)

41. Jaundice

Condition Yes No Unknown

42. Kidney disease or impaired kidney function

43. Liver tumor

44. Migraine or other headaches with neurological symptoms

45. Mitral valve prolapse 46. Neurological disease or condition (such as Parkinson's disease, paralysis)

47. Ovarian cysts

48. Peripheral vascular disease

49. Portal Vein Thrombosis

50. Premenstrual dysphoric disorder (or "PMDD")

51. Premenstrual syndrome (or "PMS")

53. Pulmonary Embolism (PE)

54. Retinal bleed

55. Rheumatological condition

56. Seizure disorder or epilepsy

57. Shortness of breath

58. Stroke or brain hemorrhage (any type)

59. Transient Ischemic Attack (TIA)

60. Varicose veins

61. Vasculitis

(b) For each condition for which you answered "Yes" in the previous chart, please provide the information requested below (and attach additional pages as necessary):

Condition Approximate Name, Address and Telephone Number

Date of Onset of Treating Health Care Provider or

Health Care Facility

V.ADDITIONAL MEDICATIONS

1. Do you currently take, or have you ever taken in the last ten (10) years, any of the following medications (generic name is followed brand name products in [brackets]):

Name of Medication Yes No Not sure/

Unknown/

Do Not Recall

1. ACE inhibitors (e.g., captopril [Capoten], enalapril maleate [Vasotec], lisinopril [Zestril] benazepril [Lotensin], fosinopril [Monopril], moexipril [Univasc], perindopril [Aceon], quinapril [Accupril], ramipril [Altace], trandolapril [Mavik])

2. Aldosterone antagonists (e.g., spironolactone [Aldactone], eplerenone [Inspra])

3. Angiotensin-II receptor antagonists (e.g., losartan [Cozaar], valsartan [Diovan], irbesartan [Avapro], candesartan [Atacand], eprosartan [Teveten], olmesartan [Benicar], telmisartan [Micardis])

4. Antibiotics (e.g., ampicillin, tetracycline, griseofulvin)

5. Anticoagulants (e.g., Coumadin, Warfarin, Fragmin, Lovenox, or Heparin)

6. Anticonvulsants (e.g., Phenobarbital, phenytoin [Dilantin], carbamazepine [Tegetrol])

7. Any medications for migraine headaches

8. Ascorbic acid [Vitamin C]

9. Asthma/breathing medications

10. Atorvastatin [Lipitor]

11. Blood pressure medications

Name of Medication Yes No Not sure/

Unknown/

Do Not Recall

12. Diuretics

13. Heart medications (excluding aspirin)

14. Minocycline (e.g.,[Myrac, Dynacin])

15. NSAIDs (e.g., ibuprofen [Motrin, Advil], naproxen [Naprosyn, Aleve])

16. Phenylbutazone

17. Potassium supplement

18. Potassium-sparing diuretics (e.g., amiloride [Midamor], triamterene [Dyrenium])

19. Rifampin [Rifadin]

20. St. John's Wort (hypericum perforatum)

21. Thyroid Medications

(a) If you indicated "Yes" for any of the above medications/drugs, please provide the information requested below (and attach additional pages as necessary):

Name of Medication/Drug Dates of Use Name, Address and Telephone Used (approx.) Number of prescribing Health Care

Provider or Health Care Facility

2. Are there any prescription medications that you have taken on a regular basis in the past ten (10) years?

Yes______ No______

(a) If "Yes", please for each prescription medication provide the following information:

Name of Prescription The health care Approximate Your Medication Used on a provider(s) that dates/years taken understanding as Regular Basis Prescribed the to why you were

Medication taking the

Medication

3. For the 20 days before the onset of the injuries for which recovery is sought in this action, please identify whether you have taken/ingested any of the following:

Name of Medication/Drug/Supplement Yes No Do Not Recall

1. Ephedra

2. Prescription diet medications

3. Cocaine/crack cocaine

4. Attention deficit medications

5. Heroin or methadone

Name of Medication/Drug/Supplement Yes No Do Not Recall

6. Marijuana or hashish

7. LSD, ecstasy, ICE, PCP, MDMA

8. Amphetamines

9. Inhaled non-prescriptive substances (e.g., glue or toluene)

10. Caffeine pills containing stimulants (e.g., No-Doz, Vivarin)

11. Over the counter appetite suppressants

12. Dietary supplements

13. Herbal products

14. Steroids

(a) If you indicated "Yes" for any of the above medications/drugs, please provide the information requested below (and attach additional pages as necessary):

Name of Medication/Drug/Supplement Approximate Date used (that is within 20 days of your alleged Yaz® and/or Yasmin® and/or Ocella® related injury)

4. Except for the medications/drugs/supplements identified in question 3 above, for the twenty (20) day period before the onset of the injuries for which recovery is sought in this action, set forth: (a) the name of each and every over the counter and prescription drug product ingested or otherwise used by you (including all vitamins, nutritional supplements, and all herbal and homeopathic medications and remedies); (b) the date of each ingestion or use; (c) the dosage ingested and frequency of use; (d) the purpose for using each such product; (e) the prescribing physician, if any; (f) the pharmacy or store where the product was purchased; and (g) the date of purchase. Attach additional sheets as necessary.

Name of over-the- Date(s) of Dosage Purpose Prescribing Pharmacy Date of purchase: counter or ingestion ingested or of use: health care or store prescription drug: or use: used and provider (if where frequency: any): purchased:

VI.PREGNANCY HISTORY

1. Have you ever been pregnant? Yes ___________ No ________

a. If "Yes", state your total number of pregnancies: ______

b. If "Yes", state your total number of live births: ______

c. If "Yes", indicate below whether during pregnancy, you were diagnosed with or believe you experienced any of the following:

Name of Condition Yes No Unknown If "Yes", state approx. date(s)

Toxemia

Gestational Diabetes

Pre-eclampsia

Miscarriages

VII.FAMILY MEDICAL HISTORY

1. Please indicate, to the best of your knowledge, whether your parents, sibling, or grandparents have ever suffered from any of the following:

Condition Yes No I Don't

Know

1. Abnormality of blood vessels

2. Aneurysm

3. Angina or chest pain

4. Arteriovenous malformation

5. Autoimmune disease or condition (e.g., lupus, rheumatoid arthritis, psoriasis, scleroderma, or mixed connective tissue disorder)

6. Bleeding disorder

7. Blood clots or thrombosis or any other blood clotting disorder

8. Blood disorders or dyscrasias (abnormal blood cells)

9. Brain Tumors

10. Cancer

11. Cerebrovascular disease or condition

12. Deep vein thrombosis (DVT)

13. Diabetes

14. Elevated Cholesterol

15. Glandular disease (such as malfunction of the pancreas, parathyroid, thyroid, adrenal or pituitary)

16. Heart attack

17. Heart disease

18. Heart valve disease or abnormality

19. Hypercoagulable conditions

20. Hypertension or high blood pressure

21. Hypotension

22. Increased C-reactive protein (CRP) levels

23. Infectious disease (within the past year, such as tuberculosis, pneumonia, rheumatic fever, typhoid fever, encephalitis, poliomyelitis, malaria, or hepatitis)

Condition Yes No I Don't

Know

24. Irregular heart beat, atrial fibrillation arrhythmia, heart palpitations, tachycardia (rapid heart beat), bradycardia (slow heart beat)

25. Migraine

26. Mitral valve prolapse

27. Neurological disease or condition (such as Parkinson's disease or paralysis)

28. Peripheral vascular disease

29. Phlebitis

30. Portal vein thrombosis

31. Pulmonary Embolism (PE)

32. Retinal bleed

33. Rheumatological condition

34. Seizure disorder or epilepsy

35. Stroke of any type or brain hemorrhage

36. Transient ischemic attack (TIA)

37. Varicose veins

38. Vasculitis

(a) For each condition for which you answered "Yes" in the immediately preceding chart, please provide the information requested below (and attach additional pages as necessary):

Condition Date of Relationship to Treatment and Outcome Name and Address

Onset You (If known) of Treating health (approx.) care provider or health care facility (If known)

VIII.USE OF CONTRACEPTIVES OTHER THAN YAZ® AND/OR YASMIN® AND/OR OCELLA®

1. Did you use contraceptives before your use of YAZ® and/or Yasmin® and/or Ocella®?

Yes No

2. If Yes, what contraceptives have you used in the past before you used YAZ® and/or Yasmin® and/or Ocella®? Check all that apply below.

Form of Contraception Yes No Unknown

(a) Oral contraceptives (e.g.,. birth control pills)

(b) Norplant (e.g.,. implants under skin)

(c) Depo-Provera® (the shot)

(d) NuvaRing®

(e) Transdermal contraceptives (e.g., Ortho Evra®)

(f) Intrauterine device (IUD)

(g) Contraceptive sponge

(h) Diaphragm

(i) Condoms

(j) Spermicide

(k) Rhythm method

(l) Other

For each "Yes" you have checked above, provide the following:

Form of contraception (i.e., precise name/type of product): Approx length of use (i.e., months/years): Pharmacy where prescription was filled (if applicable): Health care provider who prescribed it:

Form of contraception (i.e., precise name/type of product): Approx length of use (i.e., months/years): Pharmacy where prescription was filled (if applicable): Health care provider who prescribed it:

Form of contraception (i.e., precise name/type of product): Approx length of use (i.e., months/years): Pharmacy where prescription was filled (if applicable): Health care provider who prescribed it:

IX.YAZ® AND/OR YASMIN® AND/OR OCELLA® USE

1. Have you ever used Yaz®? Yes_____ No _____

2. Have you ever used Yasmin®? Yes_____ No _____

3. Have you ever used Ocella®? Yes_____ No _____

If "Yes", identify:

a) Date(s) of use:________________________________ ________

b) Provide in the chart below the name(s) and address(es) of the health care provider(s) who prescribed or provided Yaz® and/or Yasmin® and/or Ocella® to you:

Name of health care provider(s) Address of health care provider(s)

c) Provide in the chart below the name(s) and address(es) of the pharmacy(ies) or other store(s) or location(s) from which you obtained Yaz® and/or Yasmin® and/or Ocella® (if samples were provided, see no. 5, below):

Name of Pharmacy or Other Store/Location Address

4. Do you claim that you took Yaz® and/or Yasmin® and/or Ocella® to treat PMDD, PMS or acne?

PMDD: Yes______ No______

PMS: Yes______ No______

Acne: Yes______ No______

If you checked "Yes" for PMDD or PMS in the preceding questions, please state whether you saw a psychiatrist, psychologist or other mental health care provider for PMDD, PMS or the symptoms of PMDD or PMS or any psychiatric and/or psychological condition(s) relating to PMDD or PMS in the last ten (10) years:

Name of psychiatrist, Address and Telephone Reason for Treatment Approx. psychologist or other mental Dates/ health care provider Years of

Treatment/

Visits

5. Did you receive any samples of Yaz® and/or Yasmin® and/or Ocella®?

Yes______ No______ I don't recall______

If "Yes", please state the following:

a) Who gave you the sample(s): ______________________________________________

b) When were samples provided: _____________________________________________

c) How many samples did you get? ___________________________________________

6. Were you given any written instructions, including any prescriptions, packaging, package inserts, literature, or dosing instructions with your Yaz® and/or Yasmin® and/or Ocella®?

Yes______ No______ I don't recall______

If "Yes", who gave you the instructions? _________________________________

________________________________________________________________________

7. Were you given any oral instructions regarding your use of Yaz® and/or Yasmin® and/or Ocella®?

Yes______ No______ I don't recall______

If "Yes", who gave you the instructions? _________________________________

________________________________________________________________________

8. Do you have in your possession or does your attorney have the packaging from the Yaz® and/or Yasmin® and/or Ocella® you alleged to have used?

Yes______ No______

If "Yes", who currently has custody of the Yaz® and/or Yasmin® and/or Ocella® packaging? ________________________________________________________

________________________________________________________________________

9. Do you know the lot number(s) for any of the Yaz® and/or Yasmin® and/or Ocella® you received?

Yes______ No______

If "Yes", what is/are the lot number(s): __________________________________

10. Do you know the expiration date for any of the Yaz® and/or Yasmin® and/or Ocella® you received?

Yes______ No______

If "Yes", when is/was/were the expiration date(s): _________________________

11. Have you ever seen any advertisements (e.g., in magazines or television commercials) for Yaz® and/or Yasmin® and/or Ocella®?

Yes______ No______

If "Yes," identify the advertisement or commercial, and approximately when you saw the advertisement or commercial: ___________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

12. Other than through your attorneys, have you had or do you believe you have had any communication, oral or written, with any of the Defendants or their representatives (including E-mail, Text Messages, E-Minders to/from you and any of the Defendants including through websites for Yaz® and/or Yazmin® and/or Ocella® and/or signing up for an on-line program)?

Yes______ No______ I do not recall___________

Yes______ No______ I do not recall ___________

If "Yes," set forth the date of the communication, the method of communication, the name of the representative you communicated with, and the substance of the communication between you and any representatives of the Defendants: ________

________________________________________________________________________

________________________________________________________________________

X.INJURIES & DAMAGES

1. Are you claiming any injury as a result of taking Yaz® and/or Yasmin® and/or Ocella®?

Yes______ No______

If "Yes," please describe in detail your physical injury(ies) you claim were caused as result of your use of Yaz® and/or Yasmin® and/or Ocella®:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

a. When did this/these injury(ies) occur? _______________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

b. Were there any witnesses when your injury occurred or for the period of one (1) hour before your injury occurred, and if so, please state his/her/their name(s), address(es) and his/her/their relationship to you?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

c. If you were taken to a doctor or health care facility (e.g., hospital or clinic) to be treated for the injury(ies), state the name and address of the persons, police department, fire department, emergency medical workers, or ambulance company who took you to the doctor or health care facility:

Name Address

d. Were you hospitalized for this/these injury(ies)? ______________________________

Yes______ No______

If "Yes", please provide the following information:

Approximate date(s) of Approximate date(s) of Hospital name(s) and hospital admission discharge address(es):

2. Do you claim that your use of Yaz® and/or Yasmin® and/or Ocella® caused or aggravated any psychiatric and/or psychological condition(s)?

Yes______ No______

(a) If "Yes", please state the following as it pertains to your treatment of any psychiatric and/or psychological condition(s) in the last ten (10) years:

Name of psychiatrist, Address and Telephone Reason for Treatment Approx. psychologist or other mental Dates/ health care provider Years of

Treatment/

Visits

3. NOTE: ANSWER THIS QUESTION ONLY if you are alleging and claiming that you suffered a stroke or other brain injury or cognitive impairment as a result of your Yaz® and/or Yasmin® and/or Ocella® use. If so, then please answer the following:

(a) Have you been treated in the last ten (10) years for any cognitive or learning problem?

Yes______ No______

(b) If "Yes", please state the following as it pertains to your treatment for any cognitive or learning problem in the last ten (10) years:

Name of treatment Address and Telephone Reason for Approx. provider Treatment Dates/Years of

Treatment/

Visits

4. Are you making a claim for lost wages or lost earning capacity?

Yes______ No______

(a) If "Yes", state for the last five (5) years the Annual gross income you derived from your employment:

Year Annual gross income

5. If you are making a claim for lost wages (or are claiming a stroke, other brain injury, or cognitive impairment) identify the following for each employer you have had in the last five (5) years:

Name and Approx. Dates of Occupation/Job Supervisor Reason for Address of Employment Title Leaving Employer

6. Have you had any communications with your health care providers, orally or in writing, about whether your condition is related to your use of Yaz® and/or Yasmin® and/or Ocella®?

Yes______ No______ I don't recall______

(a) If "Yes", please identify the name, address and approximate date of communication with said health care provider:

7. Have you spent any money as a result of using Yaz® and/or Yasmin® and/or Ocella®?

Yes______ No______

(a) If "Yes", please identify and itemize all out-of-pocket expenses you have incurred:

XI.FACT WITNESSES

1. Please identify all persons who you believe possess information concerning your injury(ies) and current medical conditions, other than your health care providers, and please state their name, address and his/her/their relationship to you (attach additional pages as necessary):

Name Address Relationship to You

XII.DOCUMENT DEMANDS

A. AUTHORIZATIONS

1) Health care Authorizations -- For each health care provider identified in Sections III; IV; V; VII; VIII; IX and X, please provide a completed and signed (but undated) Health care Authorization in the form attached as Exhibit "A."

2) Tax Return 4506 and 4506-T IRS Forms --

a) Only if you answered "Yes" to question X.4 in the PFS and are asserting a claim for lost wages or a reduction in lost earning capacity, please provide a completed and signed IRS Form 4506 and 4506-T attached as Exhibit "B" for each year identified in your answer to question X.4.

b) If you answered "No" to question X.4 in the PFS and are not asserting a wage loss claim or a reduction in lost earning capacity, you are not required to provide IRS Form 4506 / 4506-T.

3) Authorizations for the Release of Employment Records -- If you are 1) asserting a claim for lost wages or a reduction in or lost earning capacity or 2) claiming a stroke, other brain injury, or cognitive impairment, please provide a completed and signed Employment Authorization attached as Exhibit "C" for each employer identified in your answer question

X.5.

4) Authorization for Release of Workers' Compensation Records -- If you answered "Yes" to question II.16 in the PFS, stating that you applied for workers' compensation within the past ten (l0) years, please provide a completed and signed (but undated) Authorization for Release of Workers' Compensation Records for each agency or company you submitted your application to in the last 10 years in the form attached as Exhibit "D."

5) Authorization for Release of Disability Records - If you answered "Yes" to question II.16 in the PFS, stating that you applied for disability within the past ten (l0) years, please provide a completed and signed (but undated) Authorization for Release for each agency or company you submitted your application to in the last 10 years in the form attached as Exhibit "E."

6) Educational Records - If you are 1) asserting a claim for lost wages or a reduction in or lost earning capacity or 2) claiming a stroke, other brain injury, or cognitive impairment, please provide a completed and signed Educational Authorization attached as Exhibit "F" for each educational institution for each educational institution that you listed in response to question II.12.

7) Insurance Records Authorization- For each company listed in your response to question II.15 in the PFS, please provide a completed and signed (but undated) Authorization for Release of Insurance Records in the form attached as Exhibit "G".

B. FEDERAL DISCLOSURES REQUIRED PURSUANT TO 42 U.S.C. § 1395y(b)(7) and (b)(8)

Starting on January 1, 2010, Defendants must report to the federal government certain information about every Plaintiff making a personal injury claim. Please complete the Federal Disclosure statement attached to the end of this Plaintiff Fact Sheet as Exhibit "H".

C. OTHER RELEVANT DOCUMENTS

Documents in your possession, including writings on paper or in electronic form (if you have any of the following materials in your custody or possession, please indicate which documents you have and attach a copy of them to this Plaintiff Fact Sheet):

1. All non-privileged documents you reviewed that assisted you in the preparation of the answers to this Plaintiff Fact Sheet. Yes______ No______

2. A copy of all medical records and/or documents relating to the use of Yaz® and/or Yasmin® and/or Ocella®; from any hospital or health care provider who treated you in the past 10 years and who treated you for any disease, condition or symptom referred to in any of your responses to the questions above and concerning any condition you claim is related to the use of Yaz® and/or Yasmin® and/or Ocella®, including, but not limited to, all imaging studies of any part of your body that relate in any manner to the diagnosis, treatment, care or management of your condition and the injuries alleged in your Complaint. Yes______ No______

3. If you have been the claimant or subject of any workers' compensation, social security or other disability proceeding, all documents relating to such proceeding. Yes______ No______

4. All documents constituting, concerning or relating to product use instructions, product warnings, package inserts, pharmacy handouts or other materials distributed with or provided to you in connection with your use of Yaz® and/or Yasmin® and/or Ocella®. Yes______ No______

5. Copies of advertisements or promotions for Yaz® and/or Yasmin® and/or Ocella® and articles discussing Yaz® and/or Yasmin® and/or Ocella®. Yes______ No______

6. Copies of the entire packaging, including the box and label for Yaz® and/or Yasmin® and/or Ocella® (plaintiffs or their counsel must maintain the originals of the items requested in this subpart). Yes______ No______

7. All documents relating to your purchase of Yaz® and/or Yasmin® and/or Ocella®, including, but not limited to, receipts, prescriptions, prescription records, containers, labels, or records of purchase. Yes______ No______

8. All documents known to you and in your possession which mention Yaz® and/or Yasmin® and/or Ocella® or any alleged health risks or hazards related to Yaz® and/or Yasmin® and/or Ocella® in your possession at or before the time of the injury alleged in your Complaint, other than legal documents, documents provided by your attorney or documents obtained or created for the purpose of seeking legal advice or assistance. Yes______ No______

9. All documents in your possession or anyone acting on your behalf (not your lawyer) obtained directly or indirectly from any of the Defendants. Yes______ No______

10. All documents constituting any communications or correspondence between you and any representative of the Defendants. Yes______ No______

11. All photographs, drawing, journals, slides, videos, DVDs or any other media relating to your alleged injury or your life after the incident. Yes______ No______

12. Copies of all documents you (and not your lawyer) obtained from any source related to Yaz® and/or Yasmin® and/or Ocella® or to the alleged effects of using Yaz® and/or Yasmin® and/or Ocella®. Yes______ No______

13. If you claim you have suffered a loss of earnings or earnings capacity, your federal tax returns for each of the last five (5) years or W-2s for each of the last five years. Yes______ No______

14. If you claim any loss from medical expenses, copies of all bills from any physician, hospital, pharmacy or other health care providers. Yes______ No______

15. All public statements made by or on behalf of you relating to this litigation in your possession. Yes______ No______

16. Copies of letters testamentary or letters of administration relating to your status as plaintiff (if applicable). Yes______ No______

17. Decedent's death certificate and autopsy report (if applicable). Yes______ No______

XIII.DECLARATION

Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that all of the information provided in this Plaintiff Fact Sheet is true and correct to the best of my knowledge, information and belief formed after due diligence and reasonable inquiry, that I have supplied all the documents requested in Part XII of this Plaintiff Fact Sheet, to the extent that such documents are in my possession or in the possession of my lawyers, and that I have supplied the Authorizations attached to this declaration.

Date: _________________________________

Signature

20100303

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