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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? _______________________________
This brief questionnaire will help us better understand your potential Actos claim. If you have any questions please feel free to let us know. Any answers provided are held in the strictest of confidence.

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Free Case Review 24/7
You Don’t Pay Unless You Win
Call 855.385.2529


  • This field is for validation purposes and should be left unchanged.
By submitting this form, you agree to receive telephone calls and text messages at anytime, which include hours outside of business hours (8:00 am PST – 9:00 pm PST). This is so that we may reach you as soon as possible in order to consult on your potential case.

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