Free Sheet - California

IN RE CALIFORNIA COORDINATED DIET DRUG PROCEEDINGS JCCP-4032 PLAINTIFF'S FACT SHEET This Fact Sheet and the attached List of Medical Providers and Other Sources of Information must be completed by each plaintiff in JCCP-4032 who used diet drugs or who is the representative of a person or the estate of a deceased person who used diet drugs. I. CASE INFORMATION A. Please state the following for the civil action which you filed: 1. 2. 3. Case Caption: __________________________________ JCCP Civil Action No.:___________________________ Court in which action originally brought (transferor district): _______________________________________________ 4. Original civil action number in the transferor court. Civil Action No.: _________________________________ 5. Please state name, address, telephone number, fax number and E-mail address of principal attorney representing you. ________________________________________________ Name _________________________________________________ Firm _________________________________________________ City, State and Zip Code _________________________________________________ Telephone number Fax number __________________________________________________ E-mail address B. If you are completing this questionnaire in a representative capacity (e.g., on behalf of the estate of a deceased person or a minor), please complete the following:

1.

____________________________________________ Your Name _____________________________________________ Street Address ______________________________________________ City, State and Zip Code In what capacity are you representing the individual: ________________________________________________

2.

3.

4.

5.

If you were appointed by a court, state the: _____________________________ ___________________ Court Date of Appointment

6.

Your relationship to deceased or represented person: _________________________________________________

7.

If you represent a decedent's estate, state the date of death of the decedent. _________________________________________________ [If you are completing this questionnaire in a representative capacity, please respond to the remaining questions with respect to the person who used diet drugs. Those questions using the term "You' refer to the person who used the diet drugs. If the individual is deceased, please respond as of the time immediately prior to his or her death unless a different time period is specified.]

C.

Claim Information 1. Do you claim that you have suffered a bodily injury as the result of the use of Pondimin (fenfluramine), Redux (dexfenfluramine) or phentermine?1 Yes _________ No _________

1

For a description of phentermine products see chart in Part VI. -2-

2.

If the answer to the foregoing questions is "Yes", state the nature of the injury or injuries which you claim. ____________________________________________________ ____________________________________________________ ____________________________________________________

3.

If you do not claim you have suffered a bodily injury as the result of the use of Pondimin, Redux and/or phentermine, state how you have been injured. _____________________________________________________ _____________________________________________________ _____________________________________________________

II.

PERSONAL INFORMATION A. Last Name: ____________________________________________ First Name: ____________________________________________ Middle Name or Initial: __________________________________ B. Maiden or other names used or by which you have been known: ______________________________________________________ Present Street Address: ___________________________________ _______________________________________________________ City State Zip Code D. Current or last employer: _______________________________________________________ Name _______________________________________________________ Address _______________________________________________________ Dates of Employment -3-

C.

_______________________________________________________ Occupation E. F. G. H. Social Security Number: __________________________________ Date of Birth: ___________________________________________ Sex: Male ______ Female ________

Have you ever served in any branch of the U.S. Military? Yes _______ If Yes, please state: 1. 2. What branch and the dates of service. Were you discharged for any reason relating to your health or physical condition? Yes ________ No ________ No __________

If yes, state what that condition was. _______________________________________________________ I. Have you ever been rejected from military service for any reason relating to your health or physical condition? Yes ________ No ________

If yes, state what that condition was. _____________________________________________________________

J.

Have you ever filed a worker's compensation claim? Yes ______ If yes, please state 1. Year claim was filed: __________________________________ No______

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2. 3. 4. 5.

Where claim was filed: ________________________________ Claim/docket number, if applicable_______________________ Nature of disability: __________________________________ Period of disability: _____________________________________

[Attach additional sheets if necessary to describe more than one claim] K. Have you ever filed a social security disability claim? Yes _______ If yes, please state 1. 2. 3. Year claim was filed: _____________________________ Where claim was filed: ____________________________ Nature of disability: ______________________________ No _________

4. Period of disability: _________________________________ [Attach additional sheets if necessary to describe more than one claim) L. Have you ever filed a lawsuit or made a claim, other than in the present suit, relating to any bodily injury? Yes ______ No _______

If so, state the court in which such action was filed and the civil action or docket number assigned to each such claim. action or suit. _______________________________________________________ _______________________________________________________

M.

Have you been convicted of a felony within the last 10 years? Yes ______ No _______

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III.

FAMILY INFORMATION A. Are you currently married? Yes ______ B. No ________

Has your spouse filed a loss of consortium claim? Yes ______ No ________

C. D. E. F.

Spouse's name: ________________________________________ Spouse's date of birth: ___________________________________ Spouse's occupation: ____________________________________ Has any parent, grandparent or sibling been diagnosed with heart, lung, or liver problems? Yes ______ No________ I Don't know _______

If yes, identify each such person below and provide the information requested. 1. Name ___________________________________________ Current Age (or Age at Death) ________________________ Type of Problem ___________________________________ If Applicable, Cause of Death 2. Name ____________________________________________ Current Age (or Age at Death) ________________________ Type of Problem ___________________________________ If Applicable, Cause of Death _________________________ 3. Name ____________________________________________ Current Age (or Age at Death) ________________________

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Type of Problem _______________________________ If Applicable, Cause of Death ____________________ IV. CURRENT MEDICAL CONDITION A. Do you currently suffer from any physical injuries, illnesses or disabilities (other than those you claim are caused by the ingestion if Pondimin, Redux and/or phentermine)? Yes _______ B. No _________

If the answer is yes, please state the following: 1. Identify the injury, illness, or disability and date of onset: _____________________ Injury, illness or disability 2. By whom first diagnosed: ______________________ Name _______________________ Date of onset

______________________ Address (if not otherwise provided)

V.

MEDICAL BACKGROUND A. B. Height: ___________________________________________ Weight before use of Pondimin, Redux or phentermine: _____________________________________________ C. D. Current weight: _______________________________ To the best of your knowledge, have you ever used any of the following? Substance 1. Oral contraceptives Yes ___ No ____ 2. Antidepressants ______/___/______ _____/____/______ Date First Taken Date Last Taken

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Yes ___ No _____ ______/___/______ _____/____/______ Substance 3. Heart medications Yes __ No __ 4. ______/___/______ _____/____/______ Date First Taken Date Last Taken

Blood pressure medication Yes __ No ___ ______/___/______ _____/____/______

5.

Thyroid supplements Yes___ No___ ______/___/______ _____/____/______

6.

Diuretics Yes ___ No ___ ______/___/______ _____/____/______

7.

Non-prescription intravenous injections Yes __ No ___ ______/___/______ _____/____/______

8.

Any use of cocaine, crack cocaine, or heroin or use of marijuana on more than 4 occasions Yes ___ No ___ ______/___/______ _____/____/______

9.

Amphetamines Yes __ No ___ ______/___/______ _____/____/______

10.

Inhaled non-prescription substance (e.g.. inhalation of glue or toluene) Yes __ No ___ ______/___/______ _____/____/______

11.

Methysergide (Sansert) Yes __ No ___ ______/___/______ _____/____/______

12.

Ergotamine preparations (Cafergot) Yes ____ No ____ ______/___/______ _____/____/______ -8-

Substance 13. L-tryptophan Yes __ 14. No ___

Date First Taken

Date Last Taken

______/___/______ _____/____/______

Any medication for migraine headaches Yes __ No ___ ______/___/______ _____/____/______

If yes, identify the medication E. To the best of your knowledge, have you used prescription medications (other than Pondimin, Redux or phentermine), herbal preparations, or over the counter products to control or reduce your weight Yes __ No ____ If yes, state __________________ product ___________________ product __________________ product F. ___________________________ approx. dates of use ___________________________ approx. dates of use ___________________________ approx. dates of use

Smoking history [check whichever is applicable] 1. 2. never smoked cigarettes ____________ past smoker of cigarettes ____________ date on which smoking ceased __________________ amount smoked: ____ packs per day for ______years 3. current smoker of cigarettes _______ amount smoked: _____ packs per day for _____years

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G.

Drinking history 1. Do you now or have you in the past drunk alcohol (beer, wine, whiskey, etc.)? Yes ____ No _____

If yes, check the following box which represents your greatest alcohol consumption over the last five (5) years. ______ 1-5 drinks per week _______6-10 drinks per week _______15 or more drinks per week H. To the best of your knowledge, have you ever experienced any of the following? 1. Shortness of breath not associated with vigorous exercise Persistent or recurrent pain in your chest Irregular heart beat, including heart palpitations, tachycardia and bradycardia Abnormal lack of energy Fainting, dizziness or lightheartedness

Yes ____ No _____ Yes ____ No ____

2. 3.

Yes ____No ____ Yes ___ No ____ Yes ___ No ____

4. 5. 6.

Sleep apnea, other sleep breathing disorder, or difficulty breathing Yes ___ No ____ Snoring Head pounding Significant swelling of ankles other than during pregnancy Memory loss Arthritis or joint pain Yes___ No ____ Yes___ No ____ Yes ___ No ____

7. 8. 9.

10. 11.

Yes ___ No ____ Yes ___ No ____

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I.

If you claim neurotoxic injury or a claim for mental or emotional injury over and above that usually associated with the physical injuries claimed as a result of your ingesiton of diet drugs, state whether you have experienced or been treated for any psychological, psychiatric or emotional problem prior to the use of Pondimin, Redux or phentermine. Yes ___ No _____

If yes, state: 1. Name and address of each person who treated you a. ______________________________________________ Name ______________________________________________ Address (if not otherwise provided) ______________________________________________ Name ______________________________________________ Address (if not otherwise provided) ______________________________________________ Name ______________________________________________ Address (if not otherwise provided)

b.

c.

2.

Condition for which treated ____________________________________________________

3.

When treated ____________________________________________________

J.

To the best of your knowledge, have you ever been told by a doctor or any other health care provider, that you have, may have or had any of the following: 1. Hypertension or high blood pressure Yes ___ No ___ 2. Heart murmur Yes ___ No ___ 3. Heart attack Yes ___ No ___ 4. Stroke Yes ___ No ___ 5. Blood clot to the lung (pulmonary embolism) Yes ___ No ___ 6. Blood clot in the leg and/or phlebitis Yes ___ No ___ 7. Chronic lung disease Yes ___ No ___ - 11 -

8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

42.

Interstitial parasitic lung disease Yes ___ No ___ Congenital abnormality of heart Yes ___ No ___ Congenital abnormality of lungs, thorax or diaphragm Yes ___ No ___ Hypoxia Yes ___ No ___ Portal hypertension Yes ___ No ___ Pulmonary vasculitis Yes ___ No ___ Immune system disease or dysfunction (including Aids or HIV) Yes ___ No ___ Rheumatic fever Yes ___ No ___ Cirrhosis, hepatitis or other liver disease Yes ___ No ___ Alcoholism Yes ___ No ___ Carcinoid syndrome Yes ___ No ___ Other Cancer Yes ___ No ___ If yes, specify: ________________________ ____________________________________ Pulmonary hypertension Yes ___ No ___ Pulmonary venous hypertension Yes ___ No ___ Primary pulmonary hypertension Yes ___ No ___ Heart valve lesions Yes ___ No ___ Heart valve prolapse or regurgitation Yes ___ No ___ Neurological problem Yes ___ No ___ If yes, specify: ________________________ ____________________________________ Ankylosing spondylitis Yes ___ No ___ Altitude heart disease Yes ___ No ___ Cardiac arrhythmias Yes ___ No ___ Collagen vascular disease Yes ___ No ___ Endocarditis Yes ___ No ___ Eosinophilia-myalgia syndrome (EMS) Yes ___ No ___ High cholesterol Yes ___ No ___ Hypertriglyceridemia Yes ___ No ___ Increased levels of low density lipo protein cholesterol (LDL's) Yes ___ No ___ Marfan's Syndrome Yes ___ No ___ Mediastinal Fibrosis Yes ___ No ___ Mediastinal Stenosis Yes ___ No ___ Raynaud's Disease Yes ___ No ___ Anorexia Yes ___ No ___ Bulimia Yes ___ No ___ Diabetes mellitus or other form of diabetes Yes ___ No ___ If yes, specify the type: _______________________ __________________________________________ Hypoglycemia (low blood sugar) Yes ___ No ___

43.

Gall bladder disease - 12 -

Yes ___ No ___

44. 45. 46. 47. 48. 49. 50.

51. 52. 53. 54. 55. 56. 57. 58. 59. K.

Kidney disease Yes ___ No ___ Dermatomyositis Yes ___ No ___ Lupus Yes ___ No ___ Rheumatoid Arthritis Yes ___ No ___ Connective Tissue Disease Yes ___ No ___ Scleroderma Yes ___ No ___ Other autoimmune disease Yes ___ No ___ If Yes, specify: _______________________ ____________________________________ Scarlet fever Yes ___ No ___ Sickle Cell Anemia Yes ___ No ___ Syphilis Yes ___ No ___ Thyroid disorder Yes ___ No ___ Non Malignant Tumors Yes ___ No ___ Asthma or emphysema Yes ___ No ___ Coronary artery disease Yes ___ No ___ Other heart or lung disease Yes ___ No ___ Gum disease Yes ___ No ___

If you responded yes to any of the above, please identify the condition, the date of onset and state the name of the physician or other person and, if not provided in the accompanying list, the address of the physician who made the diagnosis or informed you of the condition. 1. Condition: _________________________________________ Onset: ____________________________________________ Name and address of diagnosing physician or other person: __________________________________________________ 2. Condition: _________________________________________ Onset: _____________________________________________ Name and address of diagnosing physician or other person: __________________________________________________

3.

Condition: ______________________________________ Onset: _________________________________________

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Name and address of diagnosing physician or other person: _______________________________________________ 4. Condition: ______________________________________ Onset: _________________________________________ Name and address of diagnosing physician or other person: _______________________________________________

L.

Please indicate whether you have received any of the following treatments: 1. Heart, lung or other chest surgery Yes ___ No ___

For what condition? ________________________________________________ When? __________________________________________ Treating physician: ________________________________________________ 2. Treatment for heart attack or angina Yes ___ No ___

For what problem? _________________________________________________ When? ___________________________________________ Treating physician: __________________________________________________ 3. Pacemaker Yes ___ No ___

When? ___________________________________________

Treating physician: _________________________________________________

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4.

By-pass surgery

Yes ___ No ___

When? ___________________________________________ Treating physician: __________________________________________________ M. Have you ever received any traumatic injury to your chest? Yes ___ No ___

If yes, state when and describe the injury. ______________ Injury N. ______________________ When

To the best of your knowledge, state whether any of the following tests were administered BEFORE your use of Pondimin, Redux and/or phentermine. 1. 2. 3. 4. 5. 6. 7. 8. 9. Echocardiogram Electrocardiogram Cardiac or pulmonary artery catheterization Pulmonary function test Perfusion lung scan Chest x-ray Arterial, cardiac or pulmonary angiogram Cardio-pulmonary or thallium stress test Other diagnostic test or imaging of the heart, lungs, or pulmonary arteries or arterial pressure Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___

Yes ___ No ___

O.

For each test for which you answered yes, identify the treating physician and approximate date of the test. ______________________________ Treating Physician ___________________ Approximate date

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P.

If an echocardiogram was taken BEFORE your use of Pondimin, Redux and/or phentermine, complete the following chart as to the results or attach a copy of the test report: None Trace Mild Moderate Severe Mitral Valve Regurgitation Tricuspid Valve Regurgitation Aortic Valve Regurgitation Pulmonary Valve Regurgitation ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ _______ _______ _______ _______ ______ ______ ______ ______

Q.

To the best of your knowledge, state which of the following tests was administered AFTER your use of Pondimin, Redux or phentermine. 1. 2. 3. 4. 5. 6. 7. 8. 9. Echocardiogram Electrocardiogram Cardiac or pulmonary artery catheterization Pulmonary function test Perfusion lung scan Chest x-ray Arterial, cardiac or pulmonary angiogram Cardio-pulmonary or thallium stress test Other diagnostic test or imaging of the heart, lungs, or pulmonary arteries or arterial pressure Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___

Yes ___ No ___

R.

For each test for which you answered yes, identify the treating physician and approximate date on which the tests were done. ______________________________________ Treating Physician _______________ Approximate date

S.

If an echocardiogram was taken AFTER your use of Pondimin, Redux and/or phentermine, complete the following chart as to the results or attach a copy of the test results:

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None Trace Mild Moderate Severe Mitral Valve Regurgitation Tricuspid Valve Regurgitation Aortic Valve Regurgitation Pulmonary Valve Regurgitation VI. DIET DRUG USE A. Please complete the following chart with respect to each diet medication you have taken: (if you took more than one type of phentermine product, please complete this chart, including a description, for each separate phentermine product].
Description: Color/Shape/Writing/Name 15 mg. capsule; white cap with black stripe; "REDUX" orange round tablet; 20 mg. Approximate Date First Taken Approximate Date Last Taken Prescribed/Dispensed by: (Doctor or Clinic)

____ ____ ____ ____

____ ____ ____ ____

____ ____ ____ ____

_______ _______ _______ _______

______ ______ ______ ______

Drug Name: Generic/Brand dexfenfluramine/Redux

fenfluramine/Pondimin phentermine phentermine phentermine

B.

If you took phentermine, please state the brand name(s) and manufacturer/distributor of the phentermine product(s) you took, to the extent known to you. 1. Brand Name:

Manufacturer/Distributor 2. Brand Name:

Manufacturer/Distributor C. If you took phentermine, please check the description of each phentermine - 17 -

product which you took.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

white capsule with blue cap; "Adipex-P" "37.5" on cap and two dark stripes on body white caplet with blue spots; 37.5 mg.; "LEMMON" - "99" with center score Peanut shaped, green tablet imprinted with "S" on both sides; 37.5 mg. 30 mg.; blue and clear capsule with blue and white beads; imprinted with "BMP 147," "Fastin" and/or "Beecham" white tablet with blue dots; oval; 37.5 mg. green round tablet; 8 mg. orange round tablet; 8 mg. yellow oblong tablet; 37.5 mg. black-yellow capsule; 37.5 mg. black-black capsule; 37.5 mg. brown-clear capsule; 37.5 mg. green-clear capsule; 37.5 mg. red-black capsule; 37.5 mg. yellow-yellow capsule; 37.5 yellow-yellow capsule; 30 mg. green-clear capsule; 30 mg. brown-clear capsule; 30 mg. black-black capsule; 30 mg. blue-clear capsule; 30 mg. - 18 -

20. 21. 22. 23. 24.

gray-yellow capsule; 15 mg. yellow-gray capsule: 18.75 mg. imprinted "18.75" yellow-gray capsule; 15 mg.; imprinted "E882" yellow-yellow capsule; 30 mg.; imprinted "E647" blue-white gel capsule; "E5000"; 30 mg.

25.

37.5 mg. tablet with blue dots

26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

Resin; yellow-Yellow capsule imprinted with "IONAMIN 30" Resin; yellow-gray capsule imprinted with "IONAMIN 15" Hard yellow gel capsule; 30 mg.; "RPC-69" green-clear gel capsule; 37.5 mg.; imprinted "ABANA" and "217" black capsule yellow capsule yellow-gray capsule blue-clear capsule black gel capsule; 30 mg.; imprinted "Zantryl" Other: Please describe:

D.

36. 1 can't remember what the product looked like For each diet drug used by you, set forth the approximate date of any product change or any change or interruption in dosage.

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Product

Dosage Change/Interruption/ Product Change

Approximate Date

Product

Dosage Change/Interruption/ Product Change

Approximate Date

Product

Dosage Change/Interruption/ Product Change

Approximate Date

E.

Did you lose weight while on Pondimin, Redux or Phentermine? Yes If the answer is yes, state the amount of weight you lost the period during which the weight loss was achieved No and state

F.

State your high and low weight over the past ten years. High Low lbs. lbs. Approximate Date Approximate Date

VII.

INJURY CLAIMS A. 1. Have you had discussions with any doctor about whether your condition is related to the use of diet drugs? Yes 2. No Don't Know

If yes, check one of the following: a. I was told my condition is related to the use of diet drugs . I was told my condition is not related to the use of diet drugs . - 20 -

b.

c.

I was told my condition may be related to the use of diet drugs . I was told by the doctor that the doctor does not know whether my condition is related to the use of diet drugs . I don't recall what I was told .

d.

e. 3.

Identify the doctor or doctors

Name Address (if not otherwise provided) 4. If discussed with more than one doctor, Please copy and complete Parts 2 and 3 for each.

B.

State whether you requested that any doctor or clinic provide you with diet drugs, and, if yes, identify the drug requested. Yes No

If yes, identify the drug requested C. Were you given any written instructions or warnings regarding the use of Pondimin, Redux and/or phentermine? Yes No

If yes, state when the written instructions or warnings were given and identify each person or entity from whom you received the warnings or instructions.

Approximate date

Name of person or entity (and address if not otherwise provided) D. Were you given any oral instructions or warnings regarding the use of Pondimin, Redux and/or phentermine?

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Yes

No

If yes, state when the written instructions or warnings were given and identify each person or entity from whom you received the warnings or instructions.

Approximate date

Name of person or entity (and address if not otherwise provided) E. If you claim or expect to claim that you lost earnings or impairment of earning capacity as a result of any condition which you believe was caused by your use of diet drugs: 1. Complete the following information with respect to your employment for the past ten years. Address Type of Business/Position Dates of Employment

Employers for Past Ten Years

2.

State the total amount of time which you have lost from work as a result of any condition which you claim or believe was caused by your use of diet drugs and the amount of income which you lost.

3.

State your earned income for each of the last five years. Year ____ ____ ____ ____ ____ Income $_______________ $_______________ $_______________ $_______________ $_______________ - 22 -

F.

Have you paid or incurred any medical expenses, including amounts billed or paid by insurers and other third party payors, which arc related to any condition which you claim or believe was caused by your use of diet drugs and for which you seek recovery in the action which you have filed? Yes No

If yes, state the total amount of such expenses at this time. $________________ VIII. DOCUMENTS Attach the following documents to this declaration, to the extent that such documents are currently in your possession or in the possession of your lawyers. A. A copy of all prescriptions for diet medications, exemplars of any unused diet medications you received as a result of such prescriptions, receipts, physician or office records, drug containers, packaging and other records which show each diet drug you have taken, the period during which you have taken each, the dosage of each diet drug and the frequency with which you took each drug. A copy of all medical records from any physician hospital or health care provider, who treated you for any disease, condition or symptom referred to in your response to questions in Part V. To the extent not included in the foregoing, all records relating to any examination by a physician or other health care provider, conducted for any purpose, other than psychiatric or psychological evaluation, in the period beginning five (5) years prior to the date upon which you first used phentermine, Pondimin or Redux and continuing to date. If you have been the claimant or subject of any worker's compensation, Social Security or other disability proceeding, all documents relating to such proceeding. All diagnostic tests or test results including reports of echocardiograms. Copies of all documents from physicians, health or weight loss clinics or others relating to the use of diet drugs, or to any condition you claim is related to the use of diet drugs. All documents constituting, concerning or relating to product use instructions, product warnings, package inserts, height and weight charts, pharmacy handouts - 23 -

B.

C.

D.

E. F.

G.

or other materials distributed with or provided to you when your prescriptions for diet medications were filled. H. All documents in the nature of records regarding weight gain and weight loss such as charts recording weight loss, diaries of weight loss efforts, notes or descriptions of medicines or other substances used to control or reduce your weight and the like. Copies of all advertisements or promotions for diet drugs. If you claim you have suffered a loss of earnings or earning capacity, all documents, excluding federal tax returns, which support such claim. If you claim any loss from medical expenses, copies of all bills from any physician, hospital, pharmacy or other health care provider.

I. J.

K.

DECLARATION I declare under penalty of perjury under the laws of the State of California that all of the information provided in this Fact Sheet is true and correct to the best of my knowledge, information and belief, that I have completed the List of Medical Providers and Other Sources of Information appended hereto, which is true and correct to the best of my knowledge, information and belief, that I have supplied all the documents requested in part VII of this declaration, to the extent that such documents are in my possession or in the possession of my lawyers, and that I have supplied the authorizations attached to this declaration.

___________________________________ Signature

__________________ Date

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IN RE CALIFORNIA COORDINATED DIET DRUG PROCEEDINGS JCCP-4032 LIST OF MEDICAL PROVIDERS AND OTHER SOURCES OF INFORMATION EACH PLAINTIFF IN JCCP 4032 WHO IS REQUIRED TO COMPLETE A DECLARATION MUST FULLY AND ACCURATELY COMPLETE THIS FORM LISTING MEDICAL CARE PROVIDERS AND OTHER SOURCES OF INFORMATION AS REQUESTED. List the name and address of each of the following: A. Your current family physician:

Name Street Address City, State, Zip Code

B. 1. Name

To the best of your ability, identify each of your primary care physicians going back to birth.

Approximate dates

Last known address City, State, Zip Code

2. Name Last known address City, State, Zip Code Approximate dates

3. Name Last known address City, State, Zip Code 4. Name Last known address City, State, Zip Code C. Each cardiologist, pulmonary physician and/or heart, lung or chest surgeon who has ever seen or treated you. Approximate dates Approximate dates

1. Name Specialty Street Address City, State, Zip Code 2. Name Specialty Street Address City, State, Zip Code

-2-

3. Name Specialty Street Address City, State, Zip Code 4. Name Specialty Street Address City, State, Zip Code

D. 1. Name

Each hospital where you have ever received inpatient treatment.

Specialty Street Address City, State, Zip Code 2. Name Specialty Street Address City, State, Zip Code

-3-

3. Name Specialty Street Address City, State, Zip Code

E.

Each hospital or healthcare facility where you ever received outpatient treatment (including treatment in an emergency room).

1. Name Specialty Street Address City, State, Zip Code 2. Name Specialty Street Address City, State, Zip Code 3. Name Specialty Street Address City, State, Zip Code -4-

4. Name Specialty Street Address City, State, Zip Code 5. Name Specialty Street Address City, State, Zip Code

F.

Each other physician or healthcare provider from whom you ever received treatment with the exception of psychiatrists or psychologists.

1. Name Specialty Street Address City, State, Zip Code 2. Name Specialty Street Address City, State, Zip Code -5-

3. Name Specialty Street Address City, State, Zip Code 4. Name Specialty Street Address City, State, Zip Code 5. Name Specialty Street Address City, State, Zip Code 6. Name Specialty Street Address City, State, Zip Code

-6-

7. Name Specialty Street Address City, State, Zip Code 8. Name Specialty Street Address City, State, Zip Code 9. Name Specialty Street Address City, State, Zip Code 10. Name Specialty Street Address City, State, Zip Code

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G.

Each pharmacy, drugstore and the like where you received any prescription medication taken to control or reduce your weight:

1. Name Specialty Street Address City, State, Zip Code 2. Name Specialty Street Address City, State, Zip Code 3. Name Specialty Street Address City, State, Zip Code 4. Name Specialty Street Address City, State, Zip Code

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5. Name Specialty Street Address City, State, Zip Code

H. If but only if you claim that you suffered neurotoxic injury or mental or emotional injury over and above that usually associated with the physical injuries claimed as a result of taking diet drugs, list each psychiatrist, psychologist and/or social worker from whom you ever received treatment. 1. Name Street Address City, State, Zip Code 2. Name Street Address City, State, Zip Code 3. Name Street Address City, State, Zip Code

-9-

I.

If you ever submitted a claim for social security disability benefits, state the name and address of the office which is most likely to have records concerning your claim.

Name Street Address City, State, Zip Code

J.

If you ever submitted a claim for worker's compensation, state the name and address of the office which is most likely to have records concerning your claim.

Name Street Address City, State, Zip Code

[ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO COMPLETE EACH SUBSECTION]

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