OPIOID BANKRUPTCY QUESTIONNAIRE

Your Name*

First Last

Name of Injured (if different from above)

First Last

Address of Injured*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Date of Birth*

MM

DD

YYYY

Date of Death (if applicable)

MM

DD

YYYY

Cause of Death: (if applicable)

Next of Kin/Survivors

Is there an Estate?*

YES
NO

Was an autopsy performed?*

YES
NO

Did you or a loved one become addicted to any of the following opioids prescribed by a doctor?

As to each, list the dates of use:

OxyContin*

YES
NO

Dates of OxyContin Use

MSContin*

YES
NO

Dates of MSContin Use

Dilaudid*

YES
NO

Dates of Dilaudid Use

Butrans*

YES
NO

Dates of Butrans Use

Hydrocodone*

YES
NO

Dates of Hydrocodone Use

Oxycodone Hydrochloride*

YES
NO

Dates of Oxycodone Hydrochloride Use

Morphine Sulfate*

YES
NO

Dates of Morphine Sulfate Use

Injuries from opioids (addiction, overdose, death, brain injury, etc.)

Include dates of the injuries

Injuries from opioids

Dates of Addiction Injury

Dates of Withdrawal Injury

Dates of Overdose Injury

Dates of Loss of Job Injury

Dates of Jail Injury

Dates of Loss of Child Custody

Dates of Loss Job / Career

Dates of NAS BABY

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OPIOID BANKRUPTCY QUESTIONNAIRE

Did you or a loved one become addicted to any of the following opioids prescribed by a doctor?

Injuries from opioids (addiction, overdose, death, brain injury, etc.)

Practice Areas

Contact Information