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:


Age:*


Occupation?


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

What was the cause of death as stated on the death certificate?


What was the beginning and end date of the Accutane treatment?
to

What state did you (or the person you are inquiring on behalf of) live in while taking Accutane?


List the names of any doctors who prescribed Accutane:


What did the doctor tell you about Accutane side effects?


Did the doctor give you any printed material regarding Accutane use and side effects?
Yes No

Have you or the person you are inquiring on behalf of suffered from any of the following side effects during or after Accutane treatment?

Birth defects:
Yes No

Bone or muscle damage:
Yes No

Crohn's disease:
Yes No

Diabetes:
Yes No

Hearing loss:
Yes No

Hepatitis:
Yes No

Immune system disorder:
Yes No

Inflammatory bowel disease:
Yes No

Kidney failure:
Yes No - If yes have you had a kidney transplant? Yes No

Liver failure:
Yes No - If yes have you had a liver transplant? Yes No

Lupus:
Yes No

Multiple sclerosis:
Yes No

Pancreatitis:
Yes No

Pseudotumor cerebri:
Yes No

Psychiatric illness requiring institutionalization:
Yes No

Rectal bleeding:
Yes No

Seizures:
Yes No

Stunted growth:
Yes No

Suicide:
Yes No

Suicide attempt resulting in permanent physical injuries (or damages):
Yes No

Testicular cancer:
Yes No

Ulcerative colitis:
Yes No

Vision loss:
Yes No

If you have been diagnosed with any of the conditions above what date/dates were you diagnosed?


Please describe any other problems that Accutane has caused:


Is there a family history of any of the side effects listed above?
Yes No - if so which ones?

How did you hear about us?


If you found us via an internet search engine, which one did you use?


Additional information:

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