If you took Fen-Phen for any length of time, you may be entitled to compensation. Please complete this questionnaire to the best of your ability with as much detail as possible. If you are unsure of the dates, names, addresses, etc., submit the questionnaire and we will obtain any other necessary information at a later date. In the comments section, you may indicate any other pertinent information or requests. If you would like to contact Napoli Bern, LLP for reasons other than a Fen-Phen/Redux related personal injury claim, please email info@nblawfirm.com or call 1-888-LAW-IN-NY. Click Here if you think you have PPH as a result of taking fen-phen. There is no charge for this evaluation Important Notice to Those Whose Claims For Benefits Have Been Denied: If you have Filed a Claim for Matrix Benefits but Have Been Told That You Did Not Qualify For Compensation After an Audit...You Have the Right to Challenge That Finding. The decision by the AHP Settlement Trust may be challenged through the filing of a demand for a Show Cause Proceeding. If you are not now represented by an attorney, we may be able to help you. Have you filed a claim for Matrix benefits and been told that you did not qualify for compensation after an audit? Yes No Important Notice to Those Who Took Pondimin or Redux and Had an Echocardiogram but Were Told That You Did Not Qualify For Compensation... You May Still Qualify For a Monetary Award!!!! The Nationwide Settlement with American Home Products Corporation provides substantial benefits for those who properly registered by filing a completed Blue Form by the deadline whose condition may worsen over the next twelve years. If you had been diagnosed with at least mild mitral or aortic regurgitation and have a new echocardiogram that shows greater damage you may be entitled to a substantial monetary settlement. Did you take Pondimin or Redux and have an echocardiogram but were told that you did not qualify for compensation? Yes No Were you one of the thousands of fen-phen victims who were told that the 7th Amendment would provide you a fairer result, but your claim was rejected as non-payable? Yes No Each Field Must Be Completed. If you do not know some answers, just type "dk" in the field. Thank you. Your Name: Street Address: City: State: Zip: E-mail (required): Phone Number: Work Number: Date of Birth: Drug Usage: What medication(s) were you prescribed?: (Hold the "Ctrl" key to select more than one) Fen-Phen Redux Fenfluramine Pondimin Ioamin Adipex-P Phentermine Dexfenfluramine Other Who prescribed the medication(s)?: Height and Weight before taking the medication(s): Height:    Weight:   For what length of time did you take the medication(s) Weight after taking the medication(s): How often were you monitored by the prescribing physician: Weekly Bi-Weekly Monthly Bi-Monthly Semi-Annually Never Other Since taking the medication(s), have you experienced any of the following conditions: CONDITION  YES  NO  High Blood Pressure  Chest Pain  Shortness of Breath  Fainting  Swollen Ankles or Feet  Heart or Lung Problems  Neurological Problems  Unexplained Change in Health Have you had an Echocardiogram?   If YES, when?:   Echocardiogram results: Have you had an EKG?   If YES, when?:   EKG results: Comments/Questions? Important Legal Disclaimers: Yes No - I agree that this matter may be referred to an attorney in my area who may contact me. Yes - I understand that I am not forming a formal attorney/client relationship. This Fen Phen Questionnaire is Confidential This site is maintained by Napoli Kaiser & Bern LLP for the convenience of the public and the bar. The contents of any submission will not be disclosed to anyone but the persons monitoring the site for use in discussing potential cases from those fen phen users or victims that submit forms. This questionnaire is not class notice and completion of the questionnaire does not register one for participation in any class action. Rather, this questionnaire is intended to provide basic information necessary to evaluate the merits of any claim for compensation that you may have arising out of your use of Fenfluramine (Pondimin) contained in the Fen-Phen combination of drugs and/or Dexfenfluramine (Redux). The information will be used for no other purpose and will be kept strictly confidential as required in any attorney/client relationship. However, completion and submission of the questionnaire does not establish such a relationship and no obligations of any kind exist between you and any member of this website until further discussions and agreements are reached between the parties and an attorney/client agreement is signed. By Clicking the appropriate box below, I agree to: