Gadolinium Case Inquiry Form

* denotes required fields
Personal Information
* Name
* Address
City
State
Zip Code
Daytime Phone Number
Evening Phone
Mobile Phone
* E-mail Address
   
Case Information
Have you been diagnosed with nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD)?
 
Yes
No
Not sure
Have you been diagnosed with kidney disease?
 
Yes
No
Not sure
Are you on dialysis?
 
Yes
No
Are you the injured person?
 
Yes
No
If not, please state the name of the injured person and their relationship to you.
 
If the injured person has died, please answer the following. Cause and Date of death:
 
Please briefly summarize the nature of your complaint.
 
Have you ever had any of the following? (Check all that apply)
 
Kidney problems
Liver problems
Not sure
I have never had kidney or liver problems
Approximately when did you have an MRI or MRA test done? (Check all that apply)
 
2007
2006
2005 or earlier
Not sure
Did they inject a dye into you before or during the MRI or MRA?
 
Yes
No
Not sure
Since the MRI or MRA, have you experienced any of the following?
 
Swelling, tightening, or thickening of the skin
Skin lesions (patches, bumps or blisters)
Burning, itching or severe sharp pain in affected areas
Changes in skin texture (feeling "woody" or like orange peel)
Difficulty extending arms or legs
Muscle weakness
Deep bone pain in hips or ribs
Swelling of hands and feet
Unexplained high blood pressure
Other serious side effects
Other (Specify)  
 
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.