Please provide your name, address, telephone number(s), date of birth and relationship to the Xarelto user

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone Number

(###)

###

####

Date of Birth

YYYY

Relationship to Xarelto User

Is the Xarelto user unable to answer this questionnaire

If YES, please explain why

I. PERSONAL/BACKGROUND - XARELTO USER:

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone Number

(###)

###

####

Email Address

Date of Birth

YYYY

Social Security Number

Marital Status

If married, name of spouse

If married, date of marriage

Employment Status

Identify job, title, salary, duties and responsibilities

Are you presently receiving Medicaid benefits?

If you have declared bankruptcy, is the case still open?

Emergency Contact

First Name

Last Name

Emergency Contact Telephone Number

(###)

###

####

III. Use of Xarelto

Usage Start Date

YYYY

Usage End Date

YYYY

Were you asked to take Aspirin in combination with Xarelto?

What medical condition was Xarelto prescribed for?

Have you had a cardiac stent placed in your heart?

If Yes, provide date

YYYY

Who prescribed Xarelto to you?

Names of Physician(s)

Name of Medical Facility/Clinic/Practice

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone Number

(###)

###

####

IV. Please provide the name, address and telephone number of the pharmacy(ies) where you had your Xarelto prescription filled (please obtain copies of pharmacy records and provide if possible)

Pharmacy 1 - Name

Pharmacy 1 - Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pharmacy 1 - Telephone Number

(###)

###

####

Pharmacy 2 - Name

Pharmacy 2 - Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pharmacy 2 - Telephone Number

(###)

###

####

Injuries

Please list the date of diagnosis of the above listed injuries

Please provide the following for the physician who diagnosed the injury listed above

Names of Physician

Address of Physician

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone Number of Physician

(###)

###

####

VI. Please provide the following for the hospital/facility that treated you for the above listed injury

Name of facility/hospital

Address of facility/hospital

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone number of facility/hospital

(###)

###

####

Date of admission

YYYY

Date of discharge

YYYY

What medical treatment did you receive?

VI. Documents

If you are in possession of any of the following documents (or can get copies) kindly provide us copies at your earliest convenience: 1. Copies of the packaging, including the bottle, box and label for Xarleto; 2. Copies of prescription or receipts for Xarelto; 3. Copies of any medical or billing records from pharmacies and/or physicians relating to your use of Xarelto and your alleged injuries; and 4. Copies of any documents (i.e. instructions, warnings, advertisements) relating to Xarleto obtained from your physician, pharmacy or a newspaper. If you cannot get all or some of these documents, please submit this questionnaire and we will get the documents for you.

Xarelto Client Questionnaire

Slater Slater Schulman LLP - Questionnaire