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A CASE FOR WOMEN – Truvada Questions
Questions? Call us at
(888) 373-7888
.
Step
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PERSONAL AND CONFIDENTIAL – PROSPECTIVE CLIENT COMMUNICATION
Medication Use and Symptoms
Which medication(s) have you taken?
Truvada
Complera
Atipla
Stribild
Viread
TDF medication but unsure of brand
Other
Medication name:
When did you start taking it?
*
An approximate date is fine if you are unsure of the exact date!
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Are you still taking it?
*
Yes
No
Do you take this medication daily?
Yes
No
Please describe how often you take it:
*
When did you stop?
*
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When you were using this medication, did you take it daily?
*
Yes
No
How often did you take it?
*
Hidden
Please list any and all states that you have lived in while taking this medication:
Hidden
Have you experienced any of the following BEFORE using this medication?
Select all that apply.
Bone mineral density loss
Bone necrosis (bone death)
Bone fracture
Osteopenia
Osteoporosis
Kidney toxicity
Chronic kidney disease
Kidney damage
Kidney failure
Fanconi syndrome
None of these
Did your condition(s) worsen after you started taking this medication?
Yes
No
Have you experienced any of the following since using this medication, or have any of the following worsened since taking it?
*
Select all that apply.
Bone mineral density loss
Bone necrosis (osteonecrosis, bone death, bone deterioration)
Bone fracture (broken bones or bone collapse)
Osteopenia (brittle, weak, or fragile bones)
Osteoporosis (porous bones)
Kidney toxicity
Chronic kidney disease
Kidney damage
Kidney failure
Fanconi syndrome
None of these
Bone Mineral Density Loss
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
Date of diagnosis or most recent doctor's appointment:
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Name and address of hospital/facility:
Name of doctor:
Bone Necrosis
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
Date of diagnosis or most recent doctor's appointment:
Month
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1921
1920
Name and address of hospital/facility:
Name of doctor:
Osteopenia
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
Date of diagnosis or most recent doctor's appointment:
Month
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1922
1921
1920
Name and address of hospital/facility:
Name of doctor:
Osteoporosis
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
Date of diagnosis or most recent doctor's appointment:
Month
1
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1922
1921
1920
Name and address of hospital/facility:
Name of doctor:
Kidney Toxicity
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
Date of diagnosis or most recent doctor's appointment:
Month
1
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1922
1921
1920
Name and address of hospital/facility:
Name of doctor:
Chronic Kidney Disease
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
Date of diagnosis:
Month
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9
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1930
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Name and address of hospital/facility:
Diagnosing doctor:
Fanconi Syndrome
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
Date of diagnosis:
Month
1
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3
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5
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7
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9
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11
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1930
1929
1928
1927
1926
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1924
1923
1922
1921
1920
Name and address of hospital/facility:
Diagnosing doctor:
Bone Fracture
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
When did this happen?
Month
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1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Name and address of hospital/facility:
Name of doctor:
Kidney Damage
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
When did this happen?
Month
1
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9
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Name and address of hospital/facility:
Name of doctor:
Kidney Failure
Please fill in as much information as you remember. An approximation of dates/names/addresses is fine!
When did this happen?
Month
1
2
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5
6
7
8
9
10
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Day
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1922
1921
1920
Name and address of hospital/facility:
Name of doctor:
Hidden
Please list any other symptoms you have experienced since using this medication:
If applicable, please provide date of doctor visit, along with doctor name and address of the facility.
Is there anything else we should know about your experience?
Contact Info
Your Full Legal Name:
First Name
*
Middle Name
Last Name
*
Date of Birth
*
Month
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1920
Gender
*
Female
Male
Other
Prefer not to say
Marital Status
Single
Married
Separated
Divorced
Widowed
If you have a different last name that may be on your medical records, please list it here:
Email
Cell Number
*
Address
*
If you are able to take action, we will need this for legal purposes only.
Street Address
City
ZIP / Postal Code
State
*
Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Armed Forces Africa
Armed Forces Americas
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
Have you already signed paperwork with a lawyer, or law firm, to pursue legal action against the manufacturers of Truvada or other similar medications?
*
Yes
No
Amazing! We're so happy that you're standing up for yourself, and everyone hurt by this medication. You can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.
Great! We're so happy you're interested in standing up for yourself, and everyone hurt by this medication. Just so you know, you can only have one firm working for you on this kind of legal action. This is a national issue, and we're working with firms combating this on the national level. Whoever you choose, make sure they have the resources and experience to represent you.
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