Resource 4 Risperdal Info

Contact Information
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First Name*
Last Name
Home Phone*	- -
Work Phone*	- -
Cell Phone*	- -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip
Injured Person's Contact Information
The injured person is
First Name:
Last Name:
Home Phone:	- -
Work Phone:	- -
Cell Phone:	- -
Email Address:
Street Address:
City:
State/City
Date of Birth
Sex	Male Female

Risperdal Information
When did the person start taking Risperdal?

At what age did the person start taking Risperdal?

Is there proof of taking Risperdal?
Records from doctor?
Yes No
Pharmacy records?
Yes No
Prescription bottle?
Yes No
Why was Risperdal taken?

Is Risperdal still being taken?
Yes No
While taking Risperdal was person diagnosed with any of the following?
Neuroleptic Malignant Syndrome
Yes No
Stroke
Yes No
Stroke Like Events
Yes No
Blood Clot
Yes No
Hemorrhage
Yes No
Other
Yes No
If other, please describe:

What was the approximate proximity to diagnosis and the drug being take?

Do you or your injured person currentyl have an attorney representing you for your Risperdal Lasuit?
Yes No
Additional Comments:

	a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
	b. I agree that my information will be reviewed by more than one attorney and/or law firm.
	c. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.