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Ketek Case Evaluation Form

* Required Fields
PERSONAL INFORMATION
First Name:
Last Name:
E-mail Address:
Address:
City:
State:
Zipcode:
Phone: -- ext.
Date of Birth:
KETEK CASE INFORMATION
Did you or a loved one take Ketek?

Yes No

In what city and state were you prescribed the medication?
Did you suffer an injury as a result of taking the medication?

Yes No

Which symptoms or problems have you had?
(check all that apply)
Hepatotoxicity
blurry vision
liver transplantation
difficulty breathing
jaundice (yellow skin)
fainting spells
 abnormal liver function
itching
liver tissue death
liver problems
jaundice (yellow eyes)
skin rash
swelling of tongue or throat vomiting
redness, blistering, peeling or loosening of the skin,
         including inside the mouth
severe or watery diarrhea or persistent diarrhea
Describe what other symptoms occurred
What was the diagnosis?
Date of Diagnosis:
ADDITIONAL KETEK CASE INFORMATION
What were the dates of use?
Start Date
End Date
What other medications were being taken at that time?
Please describe your legal issues and needs.

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* Required Fields
PERSONAL INFORMATION
First Name:
Last Name:
E-mail Address:
Address:
City:
State:
Zipcode:
Phone: -- ext.
Date of Birth:
KETEK CASE INFORMATION
Did you or a loved one take Ketek?

Yes No

In what city and state were you prescribed the medication?
Did you suffer an injury as a result of taking the medication?

Yes No

Which symptoms or problems have you had?
(check all that apply)
Hepatotoxicity
blurry vision
liver transplantation
difficulty breathing
jaundice (yellow skin)
fainting spells
 abnormal liver function
itching
liver tissue death
liver problems
jaundice (yellow eyes)
skin rash
swelling of tongue or throat vomiting
redness, blistering, peeling or loosening of the skin,
         including inside the mouth
severe or watery diarrhea or persistent diarrhea
Describe what other symptoms occurred
What was the diagnosis?
Date of Diagnosis:
ADDITIONAL KETEK CASE INFORMATION
What were the dates of use?
Start Date
End Date
What other medications were being taken at that time?
Please describe your legal issues and needs.
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