Vioxx questionnaire

CONTACT INFORMATION FOR VIOXX USER:

Email address

First Name Last Name

Address

City Province BC AB SK MB ON QC NB NS NL PE NT NU YT Postal Code

Home phonework phonecell phone

 Date of Birth

If applicable:     Date of deathCause of death

CONTACT INFORMATION IF DIFFERENT FROM VIOXX USER:

Contact Email address

Contact First Name Contact Last Name

Contact Address

Contact City Contact Province BC AB SK MB ON QC NB NS NL PE NT NU YT

Contact home phonework phonecell phone

Contact Postal Code Relationship to Vioxx User

REASONS FOR TAKING VIOXX:     

                                           yes   no

Osteoarthritis                         

Rheumatoid Polyarthritis         

Menstrual pain                       

Migraine                                

Other                                     specify

VIOXX USAGE:

Date Vioxx first prescribedDate Vioxx use stopped

Frequency  daily use    occasional use                       Dosage  choose one 12.5 mg 25 mg 50 mg other

MEDICAL PROBLEMS SINCE TAKING VIOXX:

                                          yes    no

Heart Attack                          

Stroke                                   

Pulmonary embolism              

Deep vein thrombosis             

Other                                     specify

PRE-EXISTING CONDITIONS BEFORE TAKING VIOXX:

                                                        yes    no

Smoking                                                    number per day

High cholesterol                                  

High blood pressure                             

Overweight                                          

Diabetes                                             

Family history of heart problems           

Prior heart problems                            

Other                                                  specify

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All information will be kept strictly confidential

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