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How long have you been taking Vioxx?

Have you ever been hospitalized or had surgery related to taking Vioxx?
Yes No


Drugs Taken (check all that apply)

Vioxx
Bextra
Celebrex

Heart Attack? Yes No
Date:

Stroke? Yes No
Date:

Diagnosis of Stevens-Johnson Syndrome? Yes No
Date:

Were you taking the drug Vioxx/Bextra/Celebrex at the time you were diagnosed with your sroke, heart attack or Stevens-Johnson Syndrome?
Yes No

Were you addmitted to the hospital for your sroke, heart attack or Stevens-Johnson Syndrome? Yes No

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