Bextra Questionnaire

Office Locations

Tallahassee
(Map and Directions )
3375-A Capital Circle N.E.
Tallahassee, FL 32308
Toll Free Phone: (877) ALL WE DO
Local Phone: (850) 553-HELP
or (850) 422-7773
Fax: (850) 422-3449

Key West
(Map and Directions )
608 Whitehead Street
Key West, FL 33040
Toll Free Phone: (877) ALL WE DO
Local Phone: (305) 294-4585
Fax: (305) 294-7822

Thomasville
(Map and Directions )
214 West Jackson Street
Thomasville, GA 31792
Toll Free Phone: (877) ALL WE DO
Local Phone: (229) 226-HELP
(229) 226-4357

What should I do if I or a loved one took Bextra?

Name:
E-mail:
Phone:
Address:
City:
State:
Zip:

If you are responding for a Bextra user who has died of a heart attack or stroke, please provide the following and address each question for the decedent:

Decedent's Name

What was the date of death?

Cause of death?

Age of the decedent?

How long have you been taking Bextra?

What dosage were you taking?

10 mg per day
20 mg per day
Other (Please specify)

Why were you prescribed Bextra?

Has your physician told you to stop taking Bextra? Yes No

What is your date of birth?

Have you been diagnosed as having any of the following while taking Bextra?

Heart attack	Date Diagnosed (month/year):
Stroke	Date Diagnosed (month/year):

Prior to taking Bextra had you been under the care of a cardiologist? Yes No

Prior to taking Bextra had you been diagnosed as having a heart attack or stroke?

Heart attack	Date:
Stroke	Date:

Were you taking medication for any of the following prior to or while you were taking Bextra?

High blood pressure
High cholesterol
Blood thinners
Nitroglycerine

Have you had any of the following tests:

EKG	Date:
Echocardiogram	Date:
Angiogram	Date:
Angioplasty	Date:
Stress Test	Date:
Angioplasty	Date: