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Home » FLQ Questionnaire

FLQ Questionnaire

Bad drug/defective product: Fluorquinolines (FLQs): Levaquin, Cipro, & Avelox
Which of these drugs did you take?*
Injury to include, but not limited to: Peripheral Neuropathy (nerve damage, nerve pain, weakness, numbness and pain, usually in your hands and feet)
Describe the pain you’re suffering:*
Name of individual using an FLQ drug:*
Dates using an FLQ drug:*
Relation to this person, if not self:*
Name of the FLQ used:*
Why was an FLQ prescribed?*
Approximate dates of usage (be as descriptive as possible):*
Name of Doctor who prescribed the FLQ:*
For what condition was the FLQ prescribed?*
What pharmacy filled the FLQ prescription?*
Were samples of the FLQ given prior to a prescription being issued?*
Has the party using the FLQ been diagnosed with Peripheral Neuropathy?*
If so, when was the diagnosis?*
Name of Doctor who diagnosed your injuries:*
Doctor who diagnosed your injuries:*
City & State of doctor who diagnosed your injury:*
If you have not been diagnosed with Peripheral Neuropathy, what injuries are you attributing to the FLQ:*
How long after starting use of the FLQ did these injuries take to present themselves:*
Best mailing address for your file:*
Best phone number to reach you at:*
Please provide as much of this information as is possible. Once I have this information I will evaluate the claim and send to you the necessary legal documents.

Last Modified: March 22, 2016

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Bad drug/defective product: Fluorquinolines (FLQs): Levaquin, Cipro, & Avelox