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Hilliard Martinez Gonzales, LLP
Allergan Update Questionnaire
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Case ID
First Name
Last Name
Do you have any medical updates to report?
We are updating our records in preparation for discovery requests from Allergan. Please assist us by answering the following questions:
Are you currently employed?
Select
Yes
No
If yes, name of employer and title
If no, last date of employment and reason for leaving
Please provide the name of any hospitals at which you have received treatment during the last 10 years.
Please provide the names of your primary health care providers during the last 10 years
Please provide the names of any plastic surgeons that have provided medical care to you during the last 10 years
Please provide the names of any oncologists who have provided medical care to you during the last 10 years
Please provide the names and specialties of any other healthcare providers who have treated you concerning breast or breast implant-related issues during the last 10 years
Do you currently use tobacco products?
Select
Yes
No
If yes, what type of tobacco products?
If no, have you used tobacco products in the past?
Select
Yes
No
If yes, when did you stop using tobacco products?
Have you posted on Facebook or any other social media sites about your breast implants, your injuries, or the recall?
Select
Yes
No
If yes, on what site(s) did you post to?
What social media sites are you still active on?
In the past 10 years have you been convicted of a felony or crime involving dishonesty?
Select
Yes
No
If yes, please the details of the felony or crime
Have you ever signed a release of claims or warranty paperwork from Allergan?
Select
Yes
No
Do you recall seeing advertisements for Allergan breast implants before you received the textured implants?
Select
Yes
No
If yes, do you have any pamphlets or other materials about the textured implants?
Select
Yes
No
If no, what do you recall about the advertisements?
