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C:\documents and settings\administrator\my documents\giannini\notes&memos\questionnaire.wpd

LAW OFFICES OF PATRICK E. CATALANO
A PROFESSIONAL CORPORATION
SAN DIEGO OFFICE
SAN FRANCISCO OFFICE
The Koll Center
781 Beach Street, Suite 333
501 West Broadway, Suite 740
San Francisco, California 94109
San Diego, California 92101-3544
(415) 788-0207
(619) 233-3565
Fax: (415) 447-0066
Fax: (619) 233-9841
Charles S. LiMandri, Esq.
Nicholas A. Siciliano, Esq.
LAW OFFICES OF CHARLES S. LiMANDRI
LAW OFFICES OF MASRY & VITITOE
P.O. Box 9120
A Professional Corporation
16236 San Dieguito Road
5707 Corsa Avenue, Second Floor
Building 3, Suite 3-15
Westlake Village, California 91362
Rancho Santa Fe, California 92067
(818) 991-8900
(858) 759-9930
Fax: (818) 991-6200
Fax: (858) 759-9938
CLIENT QUESTIONNAIRE
Ann Giannini, et. al. v. Schering-Plough, et. al.
Client Name:______________________________________________________________ Date of diagnosis of Hepatitis C:__________________________________________ Genotype:____________________________________________________________ Viral Load (if known):__________________________________________________ Severity and type of Hepatitis C symptoms (mild, moderate, severe) prior totreatment:__________________________________________________________ _________________________________________________________________________ Other medical conditions at the time of diagnosis:___________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Who suggested PEG-Intron and/or Rebetol treatment?_________________________ _________________________________________________________________________ Was Schering-Plough the manufacturer of the PEG-Intron and/or Rebetolused?______________________________________________________________ Client QuestionnairePage 2_______________________ Did your physician describe the potential risks and benefits of this therapy? say?_____________________________________________ _________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Did your physician describe the types of serious reactions you might experience? If yes, what were these adverse reactions?___________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Date PEG-Intron and/or Rebetol therapy started:______________________________ Where was the PEG-Intron and/or Rebetol obtained? Please state the name, addressand telephone number of the pharmacy:____________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ___________________________________________________________________________ Do you have any paperwork regarding the order of PEG-Intron and/or Rebetol? Ifyes, please attach.
Were you told to wait to begin therapy until a new form of Intron was available fortreatment?__________________________________________________________ If yes, how long did you wait?__________________________________________ __________________________________________________________________________ Date PEG-Intron and/or Rebetol therapy stopped:_____________________________ Was Rebetol (ribavirin) also prescribed and if so what was the dosage?___________ __________________________________________________________________________ Client QuestionnairePage 3_______________________ Please list other medications taken at the same time:___________________________ __________________________________________________________________________ __________________________________________________________________________ Dat e o f f i r s t a d v e r s e re a c t i on t o PEG- I n t ron and/or Rebetol:____________________________________________________________ How long were you treated before your adverse reactions started?_______________ __________________________________________________________________________ ___________________________________________________________________________ Please list the adverse reactions and note their severity:________________________ __________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________________________ Do you still have these adverse reactions?__________________________________ __________________________________________________________________________ Have these adverse reactions become less or more severe?______________________ __________________________________________________________________________ Are these adverse reactions disabling?_____________________________________ _________________________________________________________________________ Were you hospitalized because of these adverse reactions?_____________________ __________________________________________________________________________ Client QuestionnairePage 4_______________________ Why do you think PEG-Intron and/or Rebetol caused these symptoms?____________ __________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Did your physician adjust your dose or discontinue treatment after you reported thesesymptoms to him/her?___________________________________________________ __________________________________________________________________________ Did you report the adverse reactions(s) to the drug company and, if so, which drugcompany (name, address, telephone number)?________________________________ __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ If yes, how did the drug company respond?__________________________________ ___________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Did you report the adverse reaction(s) to the FDA or to anyone else and, if so, pleaselist in detail:__________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________ Client QuestionnairePage 5_______________________ Do you know the lot numbers of any of the PEG-Intron and/or Rebetol or ribavirintreatments you took and, if so, please list:__________________________________ _________________________________________________________________________ _________________________________________________________________________ How did you obtain your Intron or PEG-Intron and/or Rebetoldrug?_______________________________________________________ _________________________________________________________________________ ___________________________________________________________________________ Identify by batch and lot number the PEG-Intron and/or Rebetolused?______________________________________________________________ __________________________________________________________________________

Source: http://hepatitiscfree.com/pdf/Suit-questionnaire.pdf