* First Name

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State Choose StateALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

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Date of birth of injured person (mm/dd/yyyy):

Date you were prescribed Avandia (mm/dd/yyyy):

Dates Avandia (rosiglitazone) was used (mm/dd/yyyy)

Was a heart attack suffered while taking Avandia? Yes No

If yes, indicate date of heart attack:

Please further describe injuries from Avandia:

Please describe Avandia related problems:

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