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Hilliard Martinez Gonzales, LLP
Zantac Critical Information Questionnaire
Hidden
Case Number
Zantac User Personal Information
1. Alias used from start of Zantac Usage
2. Date of birth
MM slash DD slash YYYY
3. Last 4 of SSN
*
4. Street Address
5. Street Address 2
6. City
Hidden
7. State
7. State
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
8. Zip
9. Phone
10. Email
11. Gender
Select
Male
Female
Other
12. If other, please describe
13. Marital status
Select
Single
Married
Divorced
Widowed
14. Do you have children?
Yes
No
15. If yes, how many?
Occupation Information
16. Occupation
17. Start Month
Select
January
February
March
April
May
June
July
August
September
October
November
December
18. Start Year
Please enter a number from
1950
to
2020
.
19. Is this an approximate start date?
Yes
No
20. End Month
Select
January
February
March
April
May
June
July
August
September
October
November
December
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
Select
Executor
Next of kin
Zantac user declared by court to be incompetent
Zantac user is a child
28. First name of representative
29. Last name of representative
30. Relationship of the representative to the Zantac user
Select
Parent
Guardian
Widow
Widower
Next-of-kin
31. Representative’s date of birth
MM slash DD slash YYYY
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
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
37. Representative’s zip code
Zantac Usage Information
38. Approximate first use of Zantac month
Select
January
February
March
April
May
June
July
August
September
October
November
December
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
Select
January
February
March
April
May
June
July
August
September
October
November
December
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
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
45. Start month
Select
January
February
March
April
May
June
July
August
September
October
November
December
46. Start year
Please enter a number from
1950
to
2020
.
47. Is this an approximate date?
Yes
No
48. End Month
Select
January
February
March
April
May
June
July
August
September
October
November
December
49. End year
Please enter a number from
1950
to
2020
.
50. Is this an approximate date?
Yes
No
2nd residence
51. State
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
52. Start month
Select
January
February
March
April
May
June
July
August
September
October
November
December
53. Start year
Please enter a number from
1950
to
2020
.
54. Is this an approximate date?
Yes
No
55. End Month
Select
January
February
March
April
May
June
July
August
September
October
November
December
56. End year
Please enter a number from
1950
to
2020
.
57. Is this an approximate date?
Yes
No
3rd residence
58. State
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
59. Start month
Select
January
February
March
April
May
June
July
August
September
October
November
December
60. Start year
Please enter a number from
1950
to
2020
.
61. Is this an approximate date?
Yes
No
62. End Month
Select
January
February
March
April
May
June
July
August
September
October
November
December
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
Select
Zantac injection
Zantac syrup
Zantac capsules and tablets
Ranitidien injection
Ranitidine syrup
Ranitidine capsules and tablets
66. How did you obtain it? (prescribed/OTC). If it was not prescribed, you can skip the questions about the prescription.
Select
Prescribed
OTC
Both
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Select
Zantac injection
Zantac syrup
Zantac capsules and tablets
Ranitidien injection
Ranitidine syrup
Ranitidine capsules and tablets
130. How did you obtain it? (prescribed/OTC). If it was not prescribed, you can skip the questions about the prescription.
Select
Prescribed
OTC
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Select
Zantac injection
Zantac syrup
Zantac capsules and tablets
Ranitidien injection
Ranitidine syrup
Ranitidine capsules and tablets
195. How did you obtain it? (prescribed/OTC). If it was not prescribed, you can skip the questions about the prescription.
Select
Prescribed
OTC
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
Bladder
Breast
Colorectal
Esophageal
Intestinal
Kidney
Liver
Lung
Ovarian
Pancreatic
Prostate
Uterine
Stomach
Testicular
Death related to cancer
Other
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
MM slash DD slash YYYY
256. Stage of cancer at diagnosis
Select
Stage 1
Stage 2
Stage 3
Stage 4
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
MM slash DD slash YYYY
261. Stage of cancer at diagnosis
Select
Stage 1
Stage 2
Stage 3
Stage 4
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
MM slash DD slash YYYY
266. Stage of cancer at diagnosis
Select
Stage 1
Stage 2
Stage 3
Stage 4
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?
Dyspepsia (acid indigestion)
Erosive esophagitis
Gastroesophageal reflux disease (GERD)
Heartburn
Hyperacidity
Sour stomach
Stomach ulcers
Ulcers of the intestine
Upset stomach
Zollinger-Ellison syndrome
Other
271. If other, please describe
Comments
This field is for validation purposes and should be left unchanged.