Actos Client Questionnaire

If you have been taken Actos and are interested in knowing your legal rights, please fill out the following sheet and our offices will get back to you immediately.

1. How long did you take Actos for? _________________________________________
2. Do you smoke cigarettes or any other substances? ___________________________
3. If yes, then for how many years? __________________________________________
4. Were you ever employed in a position which exposed you to potentially hazardous chemicals or industrial waste? ______________________________________________________
5. If yes then for how long and who was your employer? _________________________
6. What is your age? ________________________
7. Are you a male or female? _________________
8. Do you have diabetes? ____________________
9. Which type of diabetes? ___________________
10. When did you start taking Actos? ____________
11. Where you ever aware that Actos was in fact recalled by the FDA? __________________
12. What complications are you suffering from as a result of taking Actos? _______________
13. Did you know at the time you took Actos that it can potentially cause injury? __________
14. Did your doctor advise you of the potential risks? _______________________________
15. Is there a history of bladder cancer in your family? _______________________________