Essure Lawsuit Questionnaire

PURPOSE: The purpose of this confidential questionnaire is to gather essential information about your experience with Essure, as well as the resulting problems and injuries. Your provided information will allow us to adequately investigate your potential claim, and we cannot move forward with your potential claim until we receive your information. Please fill out this questionnaire to the best of your abilities and submit it as soon as possible.

INSTRUCTIONS: Not every question will apply to you and there is likely more space than you will need. If the question doesn’t directly apply to you, then please answer it as fully and accurately as you can. You may need to look at your medical or pharmacy records, look up a doctor or pharmacy on the internet, or even call one of your doctors or healthcare providers to get information.

*=Required Field

PERSONAL IDENTIFICATION

Name

First

Middle

Last

ADDRESS LINE 1*

ADDRESS LINE 2

CITY*

STATE*

ZIP*

Home Phone*

Cell Phone

Email address*

Date of Birth

Social Security Number*

MAILING ADDRESS (IF DIFFERENT FROM HOME/RESIDENCE)

Name

First

Middle

Last

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Home Phone

Cell Phone

Email address

Social Profiles (Facebook, Twitter, etc.)

CONTACT INFORMATION FOR A PERSON WHO WILL ALWAYS BE ABLE TO REACH YOU:

Name

First

Middle

Last

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Home Phone

Alternate Phone

E-MAIL ADDRESS

What is your relationship to this person?

FAMILY STATUS

Are you currently married?

YES

If Yes, answer the following:

Date of marriage:

State where married:

Spouse's full name:

Spouse's phone (if different from above):

Spouse's date of birth:

Are you currently separated and/or living apart from your spouse?

YES

Do you have any children?

YES

If Yes, answer the following:

Number of children:

Number of children, if any, that are financially dependent on you:

Are you financially dependent on any of your children?

YES

What is your current employment status?

Employed

Unemployed

Retired

Other (Please explain;)

IDENTIFY YOUR CURRENT EMPLOYER. IF UNEMPLOYED OR RETIRED, IDENTIFY YOUR MOST RECENT EMPLOYER:

Employer's Name:

Employer's Address:

Type of Business:

Your Occupation:

Dates Employed:

PRIOR AND CURRENT LEGAL MATTERS

Have you ever been involved in any lawsuit (divorce, bankruptcy, personal injury, other)?

YES

If yes, describe what kind of lawsuit, when, and the outcome:

Have you ever been convicted of a crime?

YES

Is another attorney already helping you regarding your injuries from Essure?

YES

If Yes, answer the following:

Name of attorney:

Name of law firm:

Attorney or law firm phone #:

Date when you retained attorney / signed contract:

MEDICAL HISTORY

Pre-Essure Implant Procedure Health Information

Prior to getting Essure, what form(s) of birth control did you use to prevent pregnancy?

IMMEDIATELY prior to getting Essure, what form of birth control did you use to prevent pregnancy?

Before getting Essure, were you ever placed on a form of birth control to control irregular menstrual bleeding, heavy menstrual bleeding or menstrual cramping?

YES

Before getting Essure, did you experience heavy periods?

YES

Before getting Essure, did you experience abnormally long periods?

YES

Before getting Essure, how painful were your periods on a scale of 1-10?

Before getting Essure, how often did you feel pelvic pain that was NOT associated with your period or with sexual intercourse?

If there is anything important that we haven't asked you about your menstrual cycle/birth control before getting Essure that you want to tell us, then use the space below to write your comments.

YOUR ESSURE USE

In what State where you living when you had the Essure device implanted?

What date did you have the Essure implanted?

Did you complete the HSG test after undergoing the Essure procedure? This is the test where you are injected with dye are told whether your coils are properly placed and whether or not your tubes are completely blocked.

YES

If yes, what were the results?

Estimate how long after undergoing the Essure procedure you began to experience those symptoms:

Additional information regarding your injuries/symptoms (including dates and locations):

Have you ever undergone a uterine ablation?

YES

Have you ever become pregnant after getting Essure?

YES

If so, was the pregnancy carried to term and did you give birth to the child?

REMOVAL/HYSTERECTOMY

Have you had the Essure device removed either through a hysterectomy or partial hysterectomy?

YES

If so, what was the date of the procedure?

If you have NOT had the device removed, have you talked to your doctor about removal?

YES

If you have NOT had the device removed, has a doctor recommended removal?

YES

MEDICAL PROVIDERS & TREATMENT

Which Doctor Implanted Essure?

Doctor's Name

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Doctor's Phone

Time Period you saw Doctor:

Which Doctor Performed your Hysterectomy (if relevant)?

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Doctor's Phone

Time Period you saw Doctor:

Any Doctor(s) Who Treated Symptoms Before and After Removal:

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Doctor's Phone

Time Period you saw Doctor:

Who is your Primary Care Physician?

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Doctor's Phone

Time Period you saw Doctor:

Who is your OBGYN?

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Doctor's Phone

Time Period you saw Doctor:

If hospitalized for any issues related to your Essure, which hospital?

ADDRESS LINE 1

ADDRESS LINE 2

CITY

STATE

ZIP

Hospital Phone

Time Admitted:

DOCUMENTS AND THINGS

If you have any of the items listed below relating to Essure or your injuries, please collect them and keep them together. Do not send these items to us at this time. We will call you to discuss what to do. Mark any items that you have.

Device labels, instructions or information sheets, printouts, or patient insert papers.
Device advertisements or coupons.
Pharmacy/prescription receipts, records, or printouts.
Doctor or hospital medical or billing records.
Health insurance company medical or billing records.

If there is anything important that we haven't asked you and you want to tell us, then use the space below to write your comments.

This field should be left blank

Essure Lawsuit Questionnaire

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