Name of the person who took Rezulin
How long was Rezulin taken? Years 01 02 03 04 05 06 07 08 09 10 10+ Months 1 2 3 4 5 6 7 8 9 10 11 12
From what date to what date? Month January February March April May June July August September October November December Year 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 to Month January February March April May June July August September October November December Year 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982
Did you have any other medical conditions before taking Rezulin?


Who prescribed Rezulin?
Have you developed any serious medical condictions since taking rezulin? yes no
If so, please provide us with a brief description:

Were you taking Rezulin to only treat diabetes? yes no
Were you taking any other drugs in combination with Rezulin
to treat deabetes? yes no
If so, please list:
Have you or anyone you know suffered any liver, heart, or pulmanary problems while taking Rezulin? yes no
Were you monitored by your doctore while taking Rezulin? yes no
If so, how often: Not Monitored Every 3 months Every 2 months Weekly Daily
What type of diebetes do you have? Choose One Unknown Type I Type II
How did you hear about this website? Choose One Internet Publication Newspaper Magazine Word of Mouth Other
First name: Last name:
Your email address: (e.g.: you@aol.com)
Address
City State Zip
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Phone Fax

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