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Areas of Practice*
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Is This About a COVID-19 Vaccine Injury?*
Did you get any of these vaccinations in the 45 days before or after the COVID-19 shot? Flu, Tetanus, Pneumonia, Measles, Mumps, Rubella, MMR, Chickenpox/Varicella, Diptheria, Pertussis, DtaP, Rotavirus, Hepatitis A or B, Meningitis, HPV.
Name of the vaccine or vaccines you got*

Flu / InfluenzaTetanusPneumonia / PneumococcalChickenpox / VaricellaMMR or MMRV (Measles, Mumps, Rubella)DTaP (Diphtheria, Tetanus, and Pertussis)HPV / GardasilWhooping Cough / PertussisRotavirusHepatitis A or Hepatitis BMeningitis / MeningococcalHib / Haemophilus Influenzae Type BPolioOther non-COVID vaccine
What year did you get the Non-COVID vaccination(s)?

Before 20222022202320242025
Have you seen a doctor or medical professional for treatment?*
What was your diagnosis?
Name/Brand of Hip Implant:*
What year was the original hip replacement surgery?

Before 2015After 2015
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?

OPMSWhole HerbsRemarkable HerbsMIT 45Hush KratomKratoMadeDr. Kratom7-OHMZPure OhmsZohm7TabzOpia HydroxyCBD American ShamanOther brand not listed above
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?

OzempicWegovyMounjaroTrulicityRybelsusZepboundOther
Was your medication the name brand or generic/compounded?

Name BrandGeneric/CompoundedI don't know
What state or states did you live in when taking the medication?
Which form of medication did you use?

Pre-loaded injection penVial of medication with syringe injectionPill formOther
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.

PancreatitisDeep Vein ThrombosisEye or vision strokeGallstones or gallbladder issuesThyroid issuesKidney issuesStomach ulcersDiabetesOther
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 experience a severe injury related to a food recall?
What kind of medical treatment did you undergo?
Do you have receipts or the packaging from the recalled food product?
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.
In what state do you currently live?
Tell us if there are additional details about your situation we should know about.
Please add additional information about what happened.
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