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Have you contacted any other lawyers about this matter?
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Your Case Information

Are you the injured person?
Yes No

If not, please state the name of the injured person and their relationship to you.
Name
Relationship

Please describe the nature of your complaint in one brief sentence.

Date of Birth of the Injured Person: (mm/dd/yyyy)

When was your surgery?
(month and year)

Where was your surgery?
(city and state)

What type of surgery did you have?

Cardiac (heart) surgery

Orthopedic (bone) surgery

Other

Unsure

If you had cardiac (heart) surgery, what surgical procedure was performed?

Cardiac artery bypass grafting (CABG)

Heart bypass surgery

Other type of heart surgery

Unsure

What complications did you experience from the surgery?

Heart attack / myocardial infarction

Heart failure / congestive heart failure

Kidney failure

Kidney dysfunction

Stroke

Encephalopathy

Other

Unsure

When did you experience these complications?

During surgery

Within 24 hours after surgery

Within 1 week after surgery

Within 1 month after surgery

Other

Unsure

What did your doctors tell you about the cause of your complications?

Side effect of Trasylol

Other surgical complication

Unknown cause

Other cause

My doctors didn't tell me the cause

Unsure

Was Trasylol used during your surgery?

Yes No Unsure

If Yes, how do you know?

Informed by doctor or nurse

Medical records

Other

Do you have copies of the medical records from your surgery?

Yes No Unsure

Before your surgery, did you have a history of any of the following?

Heart attack / myocardial infarction

Congestive heart failure

Stroke

Kidney damage or dysfunction

Encephalopathy

High or low blood pressure

Blood clots

Use of blood-thinning medications

Additional Details Related to Your Case:

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