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Have you had a blood test for heavy metals?
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Chromium Levels (PPB)
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Do you have a single or bilateral implant?
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Have you had a revision?
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Who is your current Orthopod?
What hospital?
Have you been diagnosed with bladder cancer?
Yes
No
Not sure
Do you have any of the following symptoms? (check all that apply)
Blood in the urine (bright red, dark yellow, or cola colored)
Frequent or painful urination
Frequent urinary tract infection
Lower back or abdominal pain
Not sure
Have you ever take Actos, Actoplus Met, Actoplus Met XR, or Duetact?
Yes
No
Not sure
How long did you ever take Actos, Actoplus Met, Actoplus Met XR, and/or Duetact?
More than one year
Less than 1 year
Not sure
Have you or a loved one had an Internal Bleed or Brain Hemorrhage due to Pradaxa?
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No
Not sure
Has this Internal Bleed or Brain Hemorrhage cause the death of a loved one?
Yes
No
Not sure
When was your surgery date?
mm/dd/yyyy
Was your surgery due to the following?
Pelvic Organ Prolapse (POP)
Stress Urinary Incontinence (SUI)
Hernia
Other
Did you receive a Bladder Sling?
Yes
No
Not sure
How was your Mesh Implanted?
Transvaginally
Abdominally
Other
What were you charged?
Where you charged with more than one offense?
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What is the charge for the second case?
Where were you charged?
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