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Questionnaire

Nexplanon and Implanon Free Case Evaluation Questionnaire

 

Please take a moment to go over the questions.  Once this form has been completed, our attorneys will be able to review the dates and events that happened to see if you may have a case.

NAME:
PRIMARY PHONE:

MAILING ADDRESS:

EMAIL:
DATE OF BIRTH:

DATE THE IMPLANT WAS DONE?

WHAT IS THE BRAND OF THE DEVICE
NAME/ADDRESS OF PHYSICIAN/FACILITY THAT IMPLANTED THE DEVICE

DID YOU SEE THE DOCTOR WITHIN 6 WEEKS OF IMPLANT TO CONFIRM THAT THE DEVICE WAS PLACED PROPERLY?

STATE WHERE IMPLANT TOOK PLACE:

DID YOUR IMPLANT MIGRATE, BEND OR BREAK? (Please Select)
MigratedBentBrokenNo

IF YES, WHEN DID THAT OCCUR?

WERE YOU DIAGNOSED WITH THE FOLLOWING:

STROKE

TRANSIENT ISCHEMIC ATTACK (TIA)

DEEP VEIN THROMBOSIS (DVT)

PULMONARY EMBOLISM (PE)

MYOCARDIAL INFRACTION (HEART ATTACK)

MIGRATION OF THE IMPLANT INTO THE CHEST WALL OR PULMONARY ARTERY

DID YOU EXPERIENCE ANY OF THE FOLLOWING:

REMOVAL OF THE IMPLANT BY A SURGEON

VISION PROBLEMS SEVERE ENOUGH TO BE SEEN BY A PHYSICIAN:

ISSUES THAT REQUIRED TREATMENT BY A NEUROLOGIST

TINNITUS (RINGING IN EARS):

HEAVY MENSTRUAL CYCLE AFTER IMPLANTATION:

NUMBNESS/TINGLING IN ARM:

LOSS OF ARM STRENGTH:

DESCRIBE OTHER PROBLEMS WITH THE DEVICE

DID YOU HAVE TO GO TO THE ER/HOSPITAL FOR TREATMENT?

IF YES, WHERE AND FOR HOW LONG

DID YOUR DOCTOR PERFORM AN ULTRASOUND/XRAY/MRI TO LOCATE THE DEVICE? X-rayMRIUltraSoundCT ScanNo

IF YES, WHEN?

HAS THE IMPLANT BEEN REMOVED?

IF YES: WHEN WAS IT REMOVED?

WHO REMOVED IT?

DO YOU HAVE THE REMOVED IMPLANT?

IF NOT REMOVED: WHEN DO YOU PLAN TO HAVE IT REMOVED?

DO YOU HAVE ANY PHOTOGRAPHS OF YOUR INJURY?

DID ANY DOCTOR TELL YOU THE PROBLEMS YOU WERE HAVING WERE RELATED TO THE NEXPLANON IMPLANT?

IF YES, THEN GIVE THE NAME/ADDRESS OF DOCTOR WHO DIAGNOSED THE INJURIES WERE RELATED TO THE IMPLANT

WHEN DID YOU FIRST FIND OUT THE POSSIBLE CONNECTION BETWEEN THE IMPLANT AND THE INJURY?

HOW WOULD YOU LIKE THE PAPERWORK SENT?

HOW DID YOU LEARN ABOUT ABBOTT LAW GROUP?

ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW ABOUT?