Zantac Critical Information Questionnaire – Hilliard Martinez Gonzales, LLP

Hidden

Case Number

Zantac User Personal Information

1. Alias used from start of Zantac Usage

2. Date of birth

3. Last 4 of SSN*

4. Street Address

5. Street Address 2

6. City

Hidden

7. State

8. Zip

9. Phone

10. Email

11. Gender

12. If other, please describe

13. Marital status

14. Do you have children?

Yes
No

15. If yes, how many?

Occupation Information

16. Occupation

17. Start Month

18. Start Year

Please enter a number from 1950 to 2020.

19. Is this an approximate start date?

Yes
No

20. End Month

21. End Year

Please enter a number from 1950 to 2020.

Bankruptcy Info

22. Have you ever filed for bankruptcy?

Yes
No

23. If you have filed for bankruptcy, what year did you file?

Please enter a number from 1950 to 2020.

24. If you have filed for bankruptcy, what is the state of filing? (state abbreviation)

Deceased

25. Is the Zantac user deceased?

Yes
No

Representative

26. Is the claim being brought by a representative for the Zantac user?

Yes
No

27. Reason for representation

28. First name of representative

29. Last name of representative

30. Relationship of the representative to the Zantac user

31. Representative’s date of birth

32. Last four digits of representative’s SSN

33. Representative’s phone number

34. Representative’s street address

35. Representative’s city

36. Representative’s state

37. Representative’s zip code

Zantac Usage Information

38. Approximate first use of Zantac month

39. Approximate first use of Zantac year

Please enter a number from 1950 to 2020.

40. Is this an approximate date?

Yes
No

41. Approximate last use of Zantac month

42. Approximate last use of Zantac year

Please enter a number from 1950 to 2020.

43. Is this an approximate date?

Yes
No

Residences when Zantac was used

1st residence

44. State

45. Start month

46. Start year

Please enter a number from 1950 to 2020.

47. Is this an approximate date?

Yes
No

48. End Month

49. End year

Please enter a number from 1950 to 2020.

50. Is this an approximate date?

Yes
No

2nd residence

51. State

52. Start month

53. Start year

Please enter a number from 1950 to 2020.

54. Is this an approximate date?

Yes
No

55. End Month

56. End year

Please enter a number from 1950 to 2020.

57. Is this an approximate date?

Yes
No

3rd residence

58. State

59. Start month

60. Start year

Please enter a number from 1950 to 2020.

61. Is this an approximate date?

Yes
No

62. End Month

63. End year

Please enter a number from 1950 to 2020.

64. Is this an approximate date?

Yes
No

Zantac Usage - Please provide the following information for each kind of Zantac used. You will have a chance to provide this information for more than one kind of Zantac.

1st Zantac use

65. First kind of Zantac used

66. How did you obtain it? (prescribed/OTC). If it was not prescribed, you can skip the questions about the prescription.

Questions about prescription

Prescribing doctor #1

67. If prescribed, what is the first name of the doctor who prescribed it?

68. If prescribed, what is the last name of the doctor who prescribed it?

69. If prescribed, what is the street address of the prescriber?

70. Street address 2

71. If prescribed, what is the city of the prescriber?

72. If prescribed, what is the state of the prescriber?

73. If prescribed, what is the zip code of the prescriber?

74. Might you have used your health insurance to purchase your prescription?

Yes
No

75. If you might have used your health insurance to purchase the prescription, please identify the insurer

Prescribing doctor #2

76. If prescribed, what is the first name of the doctor who prescribed it?

77. If prescribed, what is the last name of the doctor who prescribed it?

78. If prescribed, what is the street address of the prescriber?

79. Street address 2

80. If prescribed, what is the city of the prescriber?

81. If prescribed, what is the state of the prescriber?

82. If prescribed, what is the zip code of the prescriber?

83. Might you have used your health insurance to purchase your prescription?

Yes
No

84. If you might have used your health insurance to purchase the prescription, please identify the insurer

Prescribing doctor #3

85. If prescribed, what is the first name of the doctor who prescribed it?

86. If prescribed, what is the last name of the doctor who prescribed it?

87. If prescribed, what is the street address of the prescriber?

88. Street address 2

89. If prescribed, what is the city of the prescriber?

90. If prescribed, what is the state of the prescriber?

91. If prescribed, what is the zip code of the prescriber?

92. Might you have used your health insurance to purchase your prescription?

Yes
No

93. If you might have used your health insurance to purchase the prescription, please identify the insurer

OTC recommending doctors

Recommending doctor #1

94. If recommended, what is the first name of the doctor who recommended it?

95. If recommended, what is the last name of the doctor who recommended it?

96. If recommended, what is the street address of the doctor?

97. Street address 2

98. If recommended, what is the city of the doctor?

99. If recommended, what is the state of the doctor?

100. If recommended, what is the zip code of the doctor?

101. Might you have used your health insurance to purchase your prescription?

Yes
No

102. If you might have used your health insurance to purchase the prescription, please identify the insurer

Recommending doctor #2

103. If recommended, what is the first name of the doctor who recommended it?

104. If recommended, what is the last name of the doctor who recommended it?

105. If recommended, what is the street address of the doctor?

106. Street address 2

107. If recommended, what is the city of the doctor?

108. If recommended, what is the state of the doctor?

109. If recommended, what is the zip code of the doctor?

110. Might you have used your health insurance to purchase your prescription?

Yes
No

111. If you might have used your health insurance to purchase the prescription, please identify the insurer

OTC – place of purchase

112. Might you have used a health savings account to purchase your OTC Zantac?

Yes
No

113. If yes, please identify the plan

1st place of purchase

114. Name of pharmacy or other place where you purchased OTC Zantac

115. What is the street address of the place you purchased OTC Zantac?

116. Street address 2

117. What is the city of the place you purchased OTC Zantac?

118. What is the state where you purchased OTC Zantac?

119. What is the zip code of the place you purchased OTC Zantac?

2nd place of purchase

120. Name of pharmacy or other place where you purchased OTC Zantac

121. What is the street address of the place you purchased OTC Zantac?

122. Street address 2

123. What is the city of the place you purchased OTC Zantac?

124. What is the state where you purchased OTC Zantac?

125. What is the zip code of the place you purchased OTC Zantac?

Questions for both Prescription and OTC

126. Was Zantac used/administered in a hospital or inpatient facility?

Yes
No
Third Choice

127. If yes, describe use

128. What dosage was used? (25 mg, 75 mg, 150 mg, 300 mg)

2nd Zantac use info

129. Second kind of Zantac used

130. How did you obtain it? (prescribed/OTC). If it was not prescribed, you can skip the questions about the prescription.

Questions about prescription

Prescribing doctor #1

131. If prescribed, what is the first name of the doctor who prescribed it?

132. If prescribed, what is the last name of the doctor who prescribed it?

133. If prescribed, what is the street address of the prescriber?

134. Street address 2

135. If prescribed, what is the city of the prescriber?

136. If prescribed, what is the state of the prescriber?

137. If prescribed, what is the zip code of the prescriber?

138. Might you have used your health insurance to purchase your prescription?

Yes
No

139. If you might have used your health insurance to purchase the prescription, please identify the insurer

Prescribing doctor #2

140. If prescribed, what is the first name of the doctor who prescribed it?

141. If prescribed, what is the last name of the doctor who prescribed it?

142. If prescribed, what is the street address of the prescriber?

143. Street address 2

144. If prescribed, what is the city of the prescriber?

145. If prescribed, what is the state of the prescriber?

146. If prescribed, what is the zip code of the prescriber?

147. Might you have used your health insurance to purchase your prescription?

Yes
No

148. If you might have used your health insurance to purchase the prescription, please identify the insurer

Prescribing doctor #3

149. If prescribed, what is the first name of the doctor who prescribed it?

150. If prescribed, what is the last name of the doctor who prescribed it?

151. If prescribed, what is the street address of the prescriber?

152. Street address 2

153. If prescribed, what is the city of the prescriber?

154. If prescribed, what is the state of the prescriber?

155. If prescribed, what is the zip code of the prescriber?

156. Might you have used your health insurance to purchase your prescription?

Yes
No

157. If you might have used your health insurance to purchase the prescription, please identify the insurer

OTC recommending doctors

Recommending doctor #1

158. If recommended, what is the first name of the doctor who recommended it?

159. If recommended, what is the last name of the doctor who recommended it?

160. If recommended, what is the street address of the doctor?

161. Street address 2

162. If recommended, what is the city of the doctor?

163. If recommended, what is the state of the doctor?

164. If recommended, what is the zip code of the doctor?

165. Might you have used your health insurance to purchase your prescription?

Yes
No

166. If you might have used your health insurance to purchase the prescription, please identify the insurer

Recommending doctor #2

167. If recommended, what is the first name of the doctor who recommended it?

168. If recommended, what is the last name of the doctor who recommended it?

169. If recommended, what is the street address of the doctor?

170. Street address 2

171. If recommended, what is the city of the doctor?

172. If recommended, what is the state of the doctor?

173. If recommended, what is the zip code of the doctor?

174. Might you have used your health insurance to purchase your prescription?

Yes
No

175. If you might have used your health insurance to purchase the prescription, please identify the insurer

176. OTC – place of purchase

177. Might you have used a health savings account to purchase your OTC Zantac?

Yes
No

178. If yes, please identify the plan

1st place of purchase

179. Name of pharmacy or other place where you purchased OTC Zantac

180. What is the street address of the place you purchased OTC Zantac?

181. Street address 2

182. What is the city of the place you purchased OTC Zantac?

183. What is the state where you purchased OTC Zantac?

184. What is the zip code of the place you purchased OTC Zantac?

2nd place of purchase

185. Name of pharmacy or other place where you purchased OTC Zantac

186. What is the street address of the place you purchased OTC Zantac?

187. Street address 2

188. What is the city of the place you purchased OTC Zantac?

189. What is the state where you purchased OTC Zantac?

190. What is the zip code of the place you purchased OTC Zantac?

Questions for both Prescription and OTC

191. Was Zantac used/administered in a hospital or inpatient facility?

Yes
No

192. If yes, describe use

193. What dosage was used? (25 mg, 75 mg, 150 mg, 300 mg)

3rd Zantac use info

194. Third kind of Zantac used

195. How did you obtain it? (prescribed/OTC). If it was not prescribed, you can skip the questions about the prescription.

Questions about prescription

Prescribing doctor #1

196. If prescribed, what is the first name of the doctor who prescribed it?

197. If prescribed, what is the last name of the doctor who prescribed it?

198. If prescribed, what is the street address of the prescriber?

199. Street address 2

200. If prescribed, what is the city of the prescriber?

201. What is the state where you purchased OTC Zantac?

202. If prescribed, what is the zip code of the prescriber

203. Might you have used your health insurance to purchase your prescription?

Yes
No

204. If you might have used your health insurance to purchase the prescription, please identify the insurer

Prescribing doctor #2

205. If prescribed, what is the first name of the doctor who prescribed it?

206. If prescribed, what is the last name of the doctor who prescribed it?

207. If prescribed, what is the street address of the prescriber?

208. Street address 2

209. If prescribed, what is the city of the prescriber?

210. What is the state where you purchased OTC Zantac?

211. If prescribed, what is the zip code of the prescriber

212. Might you have used your health insurance to purchase your prescription?

Yes
No

213. If you might have used your health insurance to purchase the prescription, please identify the insurer

Prescribing doctor #3

214. If prescribed, what is the first name of the doctor who prescribed it?

215. If prescribed, what is the last name of the doctor who prescribed it?

216. If prescribed, what is the street address of the prescriber?

217. Street address 2

218. If prescribed, what is the city of the prescriber?

219. What is the state where you purchased OTC Zantac?

220. If prescribed, what is the zip code of the prescriber

221. Might you have used your health insurance to purchase your prescription?

Yes
No

222. If you might have used your health insurance to purchase the prescription, please identify the insurer

OTC recommending doctors

Recommending doctor #1

223. If recommended, what is the first name of the doctor who recommended it?

224. If recommended, what is the last name of the doctor who recommended it?

225. If recommended, what is the street address of the doctor?

226. Street address 2

227. If recommended, what is the city of the doctor?

228. If recommended, what is the state of the doctor?

229. If recommended, what is the zip code of the doctor?

230. Might you have used your health insurance to purchase your prescription?

Yes
No

231. If yes, please identify the plan

OTC - Place of purchase

232. Might you have used a health savings account to purchase your OTC Zantac?

Yes
No

233. If yes, please identify the plan

1st place of purchase

234. Name of pharmacy or other place where you purchased OTC Zantac

235. What is the street address of the place you purchased OTC Zantac?

236. Street address 2

237. What is the city of the place you purchased OTC Zantac?

238. What is the state where you purchased OTC Zantac?

238. What is the zip code of the place you purchased OTC Zantac?

2nd place of purchase

239. Name of pharmacy or other place where you purchased OTC Zantac

240. What is the street address of the place you purchased OTC Zantac?

241. Street address 2

242. What is the city of the place you purchased OTC Zantac?

243. What is the state where you purchased OTC Zantac?

244. What is the zip code of the place you purchased OTC Zantac?

Questions for both Prescription and OTC

245. Was Zantac used/administered in a hospital or inpatient facility?

Yes
No

246. If yes, describe use

247. What dosage was used? (25 mg, 75 mg, 150 mg, 300 mg)

STOP! IF THE PERSON WHO USED ZANTAC DID NOT SUFFER CANCER, YOU DO NOT NEED TO ANSWER ANY MORE QUESTIONS. JUST GO TO THE BOTTOM AND PRESS SUBMIT.

IF THE PERSON WHO USED ZANTAC DID SUFFER CANCER, PLEASE ANSWER THE REST OF THE QUESTIONS AND THEN PRESS SUBMIT.

Injury Questions

249. Did you (or the Zantac user if you are bringing claims on behalf of someone else) experience wage loss as a result of the injuries?

Yes
No

250. If yes, please identify the lost wages

251. Were you (or the Zantac user if you are bringing claims on behalf of someone else) diagnosed with any type of cancer before you began using Zantac?

Yes
No

252. Which type of cancer do you (or the Zantac user if you are bringing claims on behalf of someone else) have as a result of using Zantac?

253. If other, what kind of cancer was it?

Please answer the questions below for every type of cancer

254. First cancer type

255. Initial date of diagnosis

256. Stage of cancer at diagnosis

257. Do you have a family history of the identified type of cancer?

Yes
No

258. If so, who is the relative?

259. Second cancer type

260. Initial date of diagnosis

261. Stage of cancer at diagnosis

262. Do you have a family history of the identified type of cancer?

Yes
No

263. If so, who is the relative?

264. Third cancer type

265. Initial date of diagnosis

266. Stage of cancer at diagnosis

267. Do you have a family history of the identified type of cancer?

Yes
No

268. If so, who is the relative?

269. Provide the name(s), specialty (general practitioner; oncologist; or other), address(es) and phone number(s) of your treating physician(s) or healthcare professional:

270. Condition(s) that prompted the use of Zantac/Ranitidine?

271. If other, please describe

Comments

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