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INVOKANA CLIENT QUESTIONNAIRE


PURPOSE: The purpose of this confidential questionnaire is to gather essential information about your use of the prescription drug Invokana, as well as the resulting problems and injuries. Your provided information will allow us to adequately investigate your potential claim, and we cannot move forward with your potential claim until we receive your information. Please fill out this questionnaire to the best of your abilities and submit it as soon as possible.

INSTRUCTIONS: Not every question will apply to you and there is likely more space than you will need. If the question doesn’t directly apply to you, then please answer it as fully and accurately as you can. You may need to look at your medical or pharmacy records, look up a doctor or pharmacy on the internet, or even call one of your doctors or healthcare providers to get information.

I. BASIC INFORMATION IF YOU ARE NOT THE INJURED PERSON


A.If you are not the injured person but are completing this questionnaire on behalf of the injured person, please answer the following questions about you, except questions 9 and 10, which are about the injured person. If you are the injured person, please skip this section and move to section II.

Mailing Address

INJURED CLAIMANT INFORMATION

The remaining questions relate to the person that was injured due to taking Invokana or another SGLT2 inhibitor (sodium-glucose co-transporter 2). If you are completing this questionnaire in a representative capacity, respond to the remaining questions with respect to the injured person. The terms “You” or “Your” refer to the injured person. If the injured person is deceased, respond as to the time immediately prior to his or her death, unless a different time period is specified.

II. IDENTIFICATION AND BACKGROUND INFORMATION

A.Personal Identification:

Mailing Address

B.Family Status:

If Yes, please answer the following:
If Yes, please answer the following:

A.Identify your current employer. If unemployed or retired, identify your most recent employer:

C.Prior & Current Legal Matters

If Yes, answer these:

III. MEDICAL HISTORY

IV. YOUR INVOKANA AND/OR INVOKAMET USE

It is extremely important to accurately and completely identify all of the facts about your Invokana prescription. A lawsuit cannot be filed against the manufacturers of Invokana without valid evidence showing that you took their drug. Evidence includes pharmacy prescription records and receipts, medical records from the doctor(s) that prescribed you Invokana, and any remaining prescription bottles or packaging.
A. Did a doctor prescribe you either of the following medications?
The following list of questions applies to the medication indicated above (if more than one medication was used, please list the specific medication along with the information requested in the question).
F. HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING INJURIES AFTER TAKING THE MEDICATION?

I. Doctor’s Name who Prescribed Invokana or Invokamet:

I. Name of Pharmacy used:

V. MEDICAL PROVIDERS

A. Diagnosing Doctor of Invokana or Invokamet Related Injuries:
B. Hospital where Invokana and/or Invokamet Injury was Treated:
C. Other Medical Providers and/or Specialists Who Treated Invokana and/or Invokamet Related Injuries.

VI. ADDITONAL PRESCRIPTION MEDICATION USE

Did a Doctor Prescribe you any of the Following Medications or other SGLT2 Inhibitors?
The following list of questions applies to the medication indicated above (if more than one medication was used, please list the specific medication along with the information requested in the question).
E. HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING INJURIES AFTER TAKING THE MEDICATION?

H. Doctor’s Name Who Prescribed the Medication:

I. Pharmacies Used:

Identify each pharmacy, drugstore, mail order pharmacy, online pharmacy, or supplier that filled your prescriptions for the medication indicated above.

VII. STATUTE OF LIMITATIONS

If Yes, answer the following questions:

B. When did you first learn any information that made you believe that your injury may be related to Invokana and Invokamet?

VIII. DOCUMENTS AND THINGS

If you have any of the items listed below relating to Invokana and/or Invokamet or your injuries, please collect them and keep them together. Do not send these items to us at this time. We will call you to discuss the next steps.
Thank you for completing this confidential questionnaire and returning it in a timely manner.