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.
1. Name of person completing this form: _________________________________________
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:
Telephone 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:
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®
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?
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?
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?
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?
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:
Name Address and Admission Reason for Admission
3. 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
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,
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).
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.)?
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):
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. __________________________________________________________________ __