Ortho Evra Information

Ortho Evra Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

If this information is not about you, then please indicate the following:

Name of the individual

Your relationship to the person named

Date of birth of named person

Notes about how you prefer to be contacted, and times when you can be reached?

When did you first start using Ortho Evra?

Did your doctor warn you of the risks associated with Ortho Evra?
Yes  No

If so, what risks were discussed?

Did you stop using Ortho Evra and, if so, when?

Have you experienced any of the following health problems?(check the box if yes)
Blood clot
Stroke
Heart attack
Pulmonary embolism
Thrombosis
Cerebral hemorrhage

Have you experienced any of the following side effects?(check the box if yes)
Difficulty breathing
Anxiety
Sharp chest pain
Tightness in chest
Fainting
Convulsion
Impaired or double vision
Partial or complete loss of vision
Coughing up blood
Pain in calf
Sudden severe headache
Numbness or weakness in arm or leg

Are there other problems or side-effects not listed above that you want to report?

Do you have a history of any of the following conditions?
Severe hypertension
Valvular heart disease
Deep vein thrombophlebitis or thromboembolic disorder
Diabetes with vascular involvement
Headaches with focal neurological symptoms
Cancer
Stroke
Heart attack

Do you have a history of any other major health problem?

Have you ever had surgery? When?

Were you immobilized for a prolonged period? How long?

Have you used birth control pills? When?

If you used the birth control pill, did you experience side effects from using the pill?

Are you a smoker? How much do you smoke a day, on average? How long have you been smoking? (Former smokers please indicate when you started and when you quit)

Please make any additional comments here:

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