*Patients Name:

*Age:

*Birthdate:

*Your Name:

*Your Relationship to Patient:

*Your Telephone Number:

*Your Mailing Address:

*E-mail address:

*In what state or states did the patient live when Trasylol was taken?

Did the patient have any of the following before taking Parotinin?

Irregular heartbeat Abdominal cardiogram Heart disease Lung disease Kidney disease Bulimia or anorexia Hypertension Diabetes High cholesterol Cardiac catheterization Echocardiogram Thyroid problem

Low calcium Low potassium Low magnesium Persistent vomitting Acute dehydration Family history of heart disease Congenital heart problems Rheumatic fever Mitral valve prolapse Cardiac artery bypass surgery Cardiac artery angioplasty Breast feeding

*During what period of time did the patient take Trasylol?
Start:

End:

Was the patient given an electrocardiogram (EKG or ECG) before Arotinin was given?
Yes  No 

What were the results?

Were the patients electrolytes checked before the patient was started on Aprtinin?
Yes  No 

*How many milligrams of Trasylol were contained in each of the Trasylol products the patien used?
Brand 1:
Brand 2:
Brand 3:
Brand 4:

Did the patient take any of the followwing during the time Trasylol was taken?
Blood Pressure Medication
Sudafed
Fen Phen
Caffeine
Mao Inhibitor
Nardil
Parnate
Anti Microbials (i.e., Furazolldone)

Has the patient experienced any of the following since he/she first took Trasylol?

Ventricular tachycardia Ventricular fibrillation Torsades de pointes QT prolongation Unusual weaknessr Unexplained vomitting Stroke Seizure Intracranial Bleed

Cardiac arrest Heart attack Difficulty breathing Shortness of breath Dizziness Fast heartbeat Irregular heartbeat Electrolyte imbalance

Why did the patient stop taking Trasylol?

In you believe the patient has had, or might have had, any kind of bad reaction to Trasylol, please explain:

In the patient have had any kind of significant health problems, please explain them here:

If there is something you wish to add, do it here: