How long have you been taking Vioxx?

What dosage were you taking?

12.5 mg per day
25 mg per day
50 mg per day
Other (Please specify

Why were you prescribed Vioxx?

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

What is your date of birth?

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

Have you experienced any of the follow symptoms while taking Vioxx?

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

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

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

High blood pressure
High cholesterol
Blood thinners
Nitroglycerine

Have you had any of the following tests:

If you are responding for a Vioxx user who has died of a heart attack or stroke:

Decedent's Name

What was the date of death?

Cause of death?

Age of the decedent?