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Is This About a COVID-19 Vaccine Injury?
Did you get the Flu and COVID vaccine shots at the same time?
Date of COVID vaccine that caused the reaction:
What year did you get the vaccination(s)?
Name of the vaccine or vaccines you got
Have you seen a doctor or medical professional for treatment?
Diagnosis:
If Diagnosis is Other, please list:
Name/Brand of Hip Implant:
What year did you have the original hip replacement surgery?
Did your doctor talk to you about metallosis, pseudotumors, high metal levels in your blood, bone loss, osteolysis, or joint loosening?
Did You Have Revision Surgery or Are You Scheduled for Revision Surgery?
Date of revision surgery or upcoming revision surgery
What are the names of the kratom brands that were used?
If Other, what was the name of the brand?
Is this about a kratom death?
If there is an autopsy report, what was the cause of death?
If there is a toxicology report, what substances are listed?
Are you a member of a tribe?
Is your question about a tribal matter?
What is the name of the tribe:
What is the tribe's location?
Did you take any of the following medications?
Was your medication the name brand or generic/compounded?
What state or states did you live in when taking the medication?
Which form of medication did you use?
Are you still taking the medication now?
Have you been diagnosed by a doctor with any of these conditions: Gastroparesis, stomach paralysis, gastric stasis, delayed gastric emptying intestinal blockage, bowel obstruction, ileal blockage?
Have you been diagnosed with any of these conditions? Check all that apply.
If Other, please describe:
Did you have non-rent paying tenants between Sept. 4, 2020 and October 2, 2021?
Do you have a copy or can you get a copy of the tenant's Eviction Protection Declaration
How many of your rental properties were impacted by the eviction moratorium?
Did you start taking Depo Provera AFTER 1992.
About how many injections of Depo-Provera have you had?
Have you been diagnosed with a meningioma tumor?
What is your diagnosis after taking Depo-Provera?
Name of the clinic or medical provider where you got the prescription for Depo-provera.
What year was the Cartiva toe implanted?
What problems did you have with the implant?
Did you have revision surgery or are you scheduled for revision surgery to remove the Cartiva implant?
How long did you use Dupixent?
Were you diagnosed with cancer or lymphoma after taking Dupixent?
In what state do you currently live?
Tell us if there are additional details about your situation we should know about.
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