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Case Information

Name of Drug

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Is the drug still being taken?Yes No
While taking the drug were you taking any additional drugs or medications?Yes No
If yes, please list names of additional drugs
Please list the side effects you or loved one has experienced
Do you feel you or your loved one has been injured from the use of this drug?Yes No
What type of injury occurred?
If death occurred, please list cause of death on death certificate
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