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If you believe that you or a loved one has been adversely affected by Primary Pulmonary Hypertension, please fill out the form below.

We value your privacy - all information that you provide, including your email address, will remain strictly confidential.

First Name
Last Name
Street Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

Injured Person Information:

Date of Birth:         -- mm/dd/yy

          Whom are you inquiring on behalf of? 

Minor Other Self

        If you are NOT inquiring on your own behalf,
        what is your relationship?

        Is the person deceased:   

Yes No

        If deceased, the date & cause of death
        as stated on the death certificate:

        Was there an autopsy performed?:

Yes No n/a

        What medication(s) were you prescribed?

        Did you take Pondimin or Redux for more than 61 days?:

Yes No

        Name of Physician that prescribed the medication(s):

        Medication Start Date:

        Medication Finish Date:

        Diagnosed with primary pulmonary hypertension (PPH):

Yes No

        Did you have a right heart catherization?

Yes No

        What were the results?

        Was Heart Valve Surgery performed?:

Yes No

Have any of the following Aortic Valve conditions been diagnosed?:

Mild Aortic Valve Regurgitation  Yes No

Moderate Aortic Valve Regurgitation  Yes No

Greater Aortic Valve Regurgitation  Yes No

Have any of the following Mitral Valve conditions been diagnosed?:

Mild Mitral Valve Regurgitation Yes No

Moderate Mitral Valve Regurgitation Yes No

Greater Mitral Valve Regurgitation Yes No

        Have any of the following Heart Conditions been diagnosed?

Atrial Fibrilation Yes No

Pulmonary Hypertension Yes No

Arrythimia Yes No

Bacterial Endocarditis Yes No

Atrial Enlargement Yes No

Was Echocardiogram performed?  Yes No

          If yes, when was Echocardiogram performed:

        Echocardiogram results:

        If Echocardiogram was not performed, please explain why:

Other Medical Conditions:

High Blood Pressure                         Yes No

Chest Pain                                        Yes No

Shortness of Breath                           Yes No

Fainting                                             Yes No

Swollen Ankles or Feet                     Yes No

Lung Problems                                  Yes No

Neurological Problems                      Yes No

Heart Problems                                 Yes No

Unexpected Change in Health          Yes No

Other Problems or Comments:

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