Garrett law office p

Garrett Law Office, P.C.
TARDIVE DYSKINESIA QUESTIONNAIRE
THIS QUESTIONNAIRE IS FOR INFORMATION PUR
POSES SO WE CAN LEARN ABOUT YOU AND YOUR CLAIM.
IT IS IMPORTANT IT BE COMPLETED EVEN IF RESPONSES ARE BASED UPON ESTIMATES, APPROXIMATE AMOUNTS, OR
APPROXIMATE DATES IN TIME TO THE BE ST OF YOUR KNOWLEDGE AND INFORMATION.
This Questionnaire is for evaluative purposes to determine whether to undertake your representation in a potential legal matter. The Information
you provide to us is for the purpose of seeking legal representation and is confidential and privileged.
Completing this Questionnaire shall not create an Attorney-Client rela tionship which can only be established after all potential conflicts of interest
can be developed, after careful consideration of the relevant facts that may pertain to your claim or claims, and a written fee agreement is entered
into between us setting forth, among ot her things, the scope of our representation.
All claims arising under state or federal law have deadlines, are time
sensitive and will be forever barred or lost if not brought within a specified
period of time after these events occurred or should have been discovered. Unless, and until, representation is offered to you by way of a written fee
agreement formally undertaking your representation in this matter,
we shall not be responsible should your putative claim not be brought in a
timely manner, or is forever barred or lost, as a result of the applicable statutes of limitation relating to your claim.
The evaluation of your claim and any tentative conclusions about any claim should not be construed or be relied upon as an opinion or
determination as to the viability or non viability of any such claim.
USER INFORMATION

Name: ______________________________________________________________________________
Address: _____________________________________________________________________________
City:________________________________
State:__________ ZIP:

Home Phone:

Work Phone:

Email Address:
EMERGENCY CONTACT / NEXT OF KIN (if different from above)
Relationship to User:
Address:
Home Phone:
Work Phone:
Have questions? Call us at 888-GARRETT (888-427-7388)
You may fax this completed form to us at 800-256-9400
Garrett Law Office, P.C.
TARDIVE DYSKINESIA QUESTIONNAIRE
MEDICAL COVERAGE
Medicaid: Yes _____
Medicare: Yes_____
Private Insurance: Yes_____
No_____ If yes:
Group / ID Number:
Address:
WHAT INSURANCE COVERAGE, IF ANY, PAID FOR TREATMENT OF YOUR SYMPTOMS OR ISSUES RELATED TO
TARDIVE DYSKINESIA?

DRUG USAGE
Has user taken (circle all that apply):
 Abilify® (aripiprazole)  Prolixin®/Modecate (fluphenazine)  Thorazine® (chlorpromazine)  Piportil (pipotiazine)  Clozaril® (clozapine)  Trilafon (perphenazine)  Haldol® (haloperidol)  Orap® (pimozide)  Seroquel® (quetiapine)  Stelazine® (trifluoperazine)  Risperdal® (risperidone)  Mellaril (thioridazine)  Serentil® (mesoridazine)  Navane® (thiothixine)  Zyprexa® (olanzapine) Have questions? Call us at 888-GARRETT (888-427-7388)
You may fax this completed form to us at 800-256-9400
Garrett Law Office, P.C.
TARDIVE DYSKINESIA QUESTIONNAIRE
Dates of Use of Medication indicated above (IMPORTANT)
Complete separately for each drug taken
Name of Drug:
___________
Date first Prescription filled:
Date last Prescription filled:
Brand Name/Generic?:
Dates of Brand name use:
Dates of Generic name use:
Physician who provided Rx or samples

Name of Drug:
___________
Date first Prescription filled:
Date last Prescription filled:
Brand Name/Generic?:
Dates of Brand name use:
Dates of Generic name use:
Physician who provided Rx or samples

Name of Drug:
___________
Date first Prescription filled:
Date last Prescription filled:
Brand Name/Generic?:
Have questions? Call us at 888-GARRETT (888-427-7388)
You may fax this completed form to us at 800-256-9400
Garrett Law Office, P.C.
TARDIVE DYSKINESIA QUESTIONNAIRE

Dates of Brand name use:
Dates of Generic name use:
Physician who provided Rx or samples
HAS USER EXPERIENCED (circle applicable injury):
Face Symptoms
 Tongue thrusting  Lip smacking  Vertical or horizontal chewing movement in the jaw  Eyebrow distortion  Frowning  Eye blinking Trunk Symptoms
 Hip rocking  Swaying of the trunk  Irregular diaphragm contractions  Head nodding  Rocking the upper torso  Shoulder shrugging Extremities Symptoms
 Piano playing movements in the fingers  Rotatory and flexion movements of the wrists  Stamping movements of the legs OTHER ADVERSE EVENTS SUFFERED BY USER:
DATE OF ADVERSE EVENT(S):
Have questions? Call us at 888-GARRETT (888-427-7388)
You may fax this completed form to us at 800-256-9400
Garrett Law Office, P.C.
TARDIVE DYSKINESIA QUESTIONNAIRE

Did adverse event occur while taking any Drug(s) indicated above? Yes: No:
Which drug? _______________________________________
If not, how soon after taking drug did event occur?

USER’S CURRENT CONDITION
Please describe User’s present condition, including complaints attributed to the adverse event:
Does User suffer from any other significant illnesses or conditions? If so, describe:
Has any healthcare professional told user that any Drug(s) indicated above caused or may have caused
TARDIVE DYSKINESIA? Yes:
If so, provide the name, address, phone number of that person and the date of each conversation:
What treatment has user had for TARDIVE DYSKINESIA? Is user still undergoing treatment?
Have questions? Call us at 888-GARRETT (888-427-7388)
You may fax this completed form to us at 800-256-9400
Garrett Law Office, P.C.
TARDIVE DYSKINESIA QUESTIONNAIRE
Who is your primary care physician/provider:
Address:
Dates Seen:
Provide a list of full names, complete addresses and dates of every healthcare provider
who treated you for your TARDIVE DYSKINESIA (s):
Address:
Dates Seen:
Address:
Dates Seen:
Address:
Dates Seen:
Provide a list of names, addresses and dates of all pharmacies used by you:
Address:
Dates Seen:
Address:
Dates Seen:
Address:
Dates Seen:
Address:
Dates Seen:
Have questions? Call us at 888-GARRETT (888-427-7388)
You may fax this completed form to us at 800-256-9400
Garrett Law Office, P.C.
TARDIVE DYSKINESIA QUESTIONNAIRE

Name:
Address:
Dates Seen:
LITIGATION INFORMATION

Are you currently represented by an attorney for claims related to an injury?
Yes __ No____
If so, who is your attorney, and what type of claim is it?


Have you notified the Drug(s) manufacturer of your injuries? Yes ____ No ____
Additional Notes- please provide any additional information you feel is important to your TARDIVEW
DYSKINESIA use:

Have questions? Call us at 888-GARRETT (888-427-7388)
You may fax this completed form to us at 800-256-9400

Source: http://www.glopc.com/wp-content/uploads/2012/10/Tardive-Dyskinesia-Questionnaire2.pdf