Accutane Side Effects Free Online Case Evaluation Form

Accutane Case Evaluation Form *Required
Your full name:*

E-mail address:*

Mailing address:*

City/State:*

Zip:*

Home number:*

Work number:

Best time to reach you if you prefer a response by telephone:

How would you like us to respond to you? (e.g., telephone, e-mail, regular mail, doesn't matter?)

Age:*

Occupation?

Side Effects?

Were any of the side effects experienced before taking Accutane?

Whom are you inquiring on behalf of?

If you are not inquiring on your own behalf, what is your relationship?

Is the person deceased?		Yes No

Date of death?

Autopsy performed ?		Yes No

If deceased, what was the cause of death as stated on the death certificate?

During what time period was Accutane taken?		Start End

List the names of any Doctors who prescribed Accutane:

How did you learn about Accutane?

Why was Accutane prescribed?

What did the Doctor tell you about Accutane side effects?

Were you given any printed materials by any doctor?

Were there any medications taken with Accutane?		Yes No

If so, please list:

Have you developed any serious medical conditions since taking Accutane?		Yes No

If so, please list:

Have you or anyone in your family suffered any liver damage, gastrointestinal disorder, central nervous system condition, or any other systemic condition? Is there a family history of the condition?		Yes No

How did you hear about us?

If you heard about us on the internet what search engine did you use?

What search term or "keyword" did you use?

Additional information:

Would you like to arrange a personal interview?		Yes No