Confidential Questionnaire

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 contained in the Fen-Phen combination of drugs and 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 California Fen-Phen Litigation Associates (CFPLA) until further discussions and agreements are reached between the parties and a fee agreement is signed.

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. Required information is indicated in red with an asterisk (*).

PERSONAL INFORMATION

1. Your current first*, middle, and last* names:

2. All former names (if any) and the years used:

3. Current mailing address:

4. City, State, Zip
,

5. Preferred E-mail address*:

6. Daytime telephone number with area code*:
e.g. 555-555-1212

7. Evening telephone number with area code:
e.g. 555-555-1212

8. Date of Birth:
e.g. MM/DD/YYYY

9. Social Security Number:
e.g. 000-00-0000

USE OF FEN-PHEN/REDUX

If you have used Fen-Phen (Pondimin or Fenfluramine Hydrochloride) or Redux (Dexfenfluramine Hydrochloride) for weight loss, please answer the following:

10. Approximate date that you first began usage:

11. Approximate date you stopped usage:

12. Name and address of the physician, medical facility or diet center that prescribed the medication to you:

13. What was your height and weight when you began taking the medication:
HEIGHT

WEIGHT

14. Select the medications that you were prescribed below:
Hold down the CONTROL key to select more than one.
Redux Fen-Phen Fenfluramine Pondimin Ioamin Adipex-P Phentermine Dexfenfluramine

15. What was your weight when you stopped taking the medication:

16. How frequently were you monitored by your prescribing physician:
Weekly Bi-Weekly Monthly Bi-Monthly Semi-Annually

17. If you took these medications during more than one period, i.e. stopped for some time and started again, please state the approximate date you began:

The date you stopped:

The date you started again:

The date you stopped again:

18. Why did you stop and start again:

19. What was your weight when you stopped the first time and each time thereafter:

20. If you took the medication during more than two periods of time, please so state and provide additional dates that you started and stopped:

21. During or since your use of these drugs, have you experienced, suspected or been diagnosed with any of the following conditions:

22. Has an Echocardiogram been performed?

23. If you answered YES to the above question, please enter date the echocardiogram was performed:

24. What other medication have you taken in the past 5 years for your medical condition:

25. What else would you like us to know about your use of Fen-Phen or Redux?

Thank you for giving us the opportunity to evaluate your case. We will contact you within ten (10) days.