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Microsoft word - questionnaire final exhibit version.doc

MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP) PLEASE NOTE THAT YOUR INFORMATION IS BEING COLLECTED BY THE LAW
FIRM OF THOMSON ROGERS (“TR”) AND/OR ITS AGENTS. TR IS CLASS COUNSEL
IN THE MIRAPEX® CLASS ACTION (Ontario Class Action No. 05-CV-288851CP)
BROUGHT AGAINST THE DEFENDANT BOEHRINGER INGELHEIM CANADA LTD.
(“BICL”). TR AND/OR ITS AGENTS ARE COLLECTING YOUR INFORMATION IN
ORDER TO EVALUATE YOUR CLAIM AND TO NEGOTIATE TOWARD A
SETTLEMENT OF THE CLASS ACTION WITH BICL IN ACCORDANCE WITH A COURT
APPROVED SETTLEMENT PROCESS. TR AND/OR ITS AGENTS MAY PROVIDE YOUR
INFORMATION TO BICL AS PART OF TR’s EFFORT TO NEGOTIATE A SETTLEMENT
OF YOUR CLAIM. HOWEVER, TR WILL OTHERWISE TREAT YOUR INFORMATION
AS CONFIDENTIAL AND TR WILL OTHERWISE MAINTAIN YOUR PRIVACY AND
THE SECURITY OF YOUR PERSONAL INFORMATION. BY SIGNING THE LAST PAGE
OF THIS FORM, YOU AUTHORIZE TR AND/OR ITS AGENTS TO RELEASE TO BICL
AND ITS INSURERS AND THEIR RESPECTIVE AGENTS OR AFFILIATES(INCLUDING
BICL’S LEGAL COUNSEL, McMILLAN LLP, A COPY OF THIS COMPLETED FORM
AND ANY RELATED INFORMATION PROVIDED TO TR BY YOU OR YOUR
PHYSICIANS FOR ANY PURPOSE RELATED TO THE CLASS PROCEEDING.

1. PERSONAL INFORMATION
a)
Full Name _____________________________________________________________
b)
Date of Birth: ___________________________________________________________
c)
Gender: Male Female
d)
Current Mailing Address:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

e)
Primary Telephone Number: ____________________________________________
____________________________________________ ____________________________________________
f) Email (if applicable):
____________________________________________ g) Provincial Health Insurance Plan Number: ____________________________________
h)
Bankruptcy: Have you ever filed for bankruptcy? Yes No
If yes, have you listed a Mirapex® claim as a potential asset? Yes No MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP)
If you answered "Yes", please advise when you filed for bankruptcy and whether and when you
were discharged:

2. MIRAPEX® AND MEDICATION HISTORY
a)
Have you ever taken the drug Mirapex®? Yes No
b)
For what condition were you taking Mirapex®?
Parkinson's Disease Restless Leg Syndrome Other (specify) _________________
If you answered "Yes" to (a), complete the following:
Start & Stop Dates & Dosage Amounts
(List all start and stop dates if there was a period of non consumption, the reason(s) why you
stopped taking Mirapex and all dosage changes along with the dates – attach extra pages if
necessary)

c)
Please provide the names and locations of the pharmacies (or other sources) where you usually
obtained Mirapex® and any other medications:

Pharmacy Name and Address: ________________________________________________
_______________________________________________ Pharmacy Name and Address: ________________________________________________ _______________________________________________ Pharmacy Name and Address: ________________________________________________ _______________________________________________ _______________________________________________
d) Have you ever taken any of the following medications?

Parlodel (generic name: Bromocriptine)
MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP)
If 'Yes' please provide your start and stop dates and dosage information (attach additional pages,
if necessary)

YOU MUST CONTACT THE PHARMACIES INVOLVED AND OBTAIN AND PROVIDE
ALL AVAILABLE PHARMACEUTICAL RECORDS LISTING ALL OF THE
MEDICATIONS (that you have listed above), INCLUDING MIRAPEX® THAT YOU HAVE
TAKEN (THE RECORDS SHOULD GO BACK AS FAR AS POSSIBLE)
(If this information is not available from the pharmacies, please obtain and provide any other
information to confirm your use of Mirapex® during these time periods)

3. MEDICAL HISTORY
a)
Before taking Mirapex®, were you ever diagnosed with or treated for any of the following
addictions, behaviours, disorders, or conditions:
 Eating disorders such as anorexia, bulimia, food addictions, or obesity  Psychological, mental, or emotional issues such as anxiety, depression, hysteria, obsessions, compulsions, mania, neurosis, or other mental health issues, bi-polar disorder  Excessive use of food, drugs, alcohol, smoking, sex, shopping, gambling, or any kind of
b)
If the answer to (a) is "Yes", please identify and provide detailed information about the nature
of the condition, the time period over which you experienced the condition, and any treatment
you received (attach additional pages if necessary):
c)
Since you stopped taking Mirapex® have you been diagnosed with or treated for any of the
addictions, behaviours, disorders, or conditions mentioned in (a)?
MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP) d) If the answer to (c) is "Yes", please identify and provide detailed information about the nature
of the condition, the time period over which you experienced the condition, and any treatment
you received (attach additional pages if necessary):

e)
To your knowledge, has a parent, sibling, or child of yours been diagnosed with, or treated for
any of the addictions, behaviours, disorders, or conditions mentioned in (a)?

4. GAMBLING HISTORY
COMPLETE THIS SECTION ONLY IF YOU ARE CLAIMING THAT MIRAPEX®
CAUSED YOU TO GAMBLE.
IF YOU DID NOT GAMBLE, THEN PLEASE PROCEED
TO SECTION 6.

a)
Before taking MIRAPEX®, how would you describe your gambling behaviour (please circle
the most accurate response):
FREQUENCY

Daily

LOCATIONS WHERE GAMBLING TOOK PLACE
(please circle all that apply)

Casino

Other (specify): ____________________________

TYPE OF GAMBLING
(please circle all that apply)

Lottery

Other (specify): ____________________________

b)
Before taking Mirapex®, how much money did you lose gambling on average per year:
Estimated amount lost per year $ ___________
c)
Before taking Mirapex®, were you taking Permax, Requip, Parlodel, or Dostinex:

d)
Have you ever won money while gambling? Yes No
MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP)
If the answer to (d) is "Yes", please fill in the following:
Date of your first win (approximate): ___________________________________
Amount of money won on that occasion: ________________________________
Location: _________________________________________________________
Type of game: _____________________________________________________

e)
Did you gamble after you stopped taking Mirapex®? Yes No
If you answered "Yes" to (e), please estimate your approximate gambling losses per year since
you stopped taking Mirapex®: _________________________________________


If you answered "No" to (e), when did you stop gambling? __________________

f)
Have you ever received therapy for gambling problems? Yes No
If you answered "Yes" to (f), please provide details of treating therapist, type of program, and
dates of treatment (attach additional pages if necessary):
5. GAMBLING WHILE TAKING MIRAPEX®
COMPLETE THIS SECTION ONLY IF YOU ARE CLAIMING THAT MIRAPEX®
CAUSED YOU TO GAMBLE
a)
While taking Mirapex®, what kinds of gambling did you engage in (identify all types of
gambling you engaged in):

b)
Over the period in which you were taking Mirapex®, did you withdraw any money from
ATMs specifically for gambling? Yes No
If "Yes" what was the total sum withdrawn from ATMs for gambling over the period in which
you were taking Mirapex® $______________

c)
Over the period in which you were taking Mirapex® did you make credit card transactions for
gambling? Yes No

If "Yes", what was the total sum withdrawn from, or charged to, credit cards for gambling over
the period in which you were taking Mirapex®: $______________
MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP) d) Describe in detail any other financial transactions you participated in to access money for
gambling over the period in which you were taking Mirapex® (attach additional pages if
necessary):

e)
What was the total sum withdrawn by means of these other financial transactions that you
used for gambling over the period in which you were taking Mirapex®?
$_______________________
f)
What are the total estimated net gambling losses (total losses minus total winnings) during the
time you were taking Mirapex®? $ _____________________________________
h)
To the extent that you filed for bankruptcy, indicate whether you claimed any gambling debts
or losses as part of your filing? Yes No

YOU MUST OBTAIN AND PROVIDE ALL DOCUMENTS CONFIRMING THESE
WITHDRAWALS OR TRANSACTIONS. IF YOU ARE RELYING ON BANK ATM
WITHDRAWALS OR CASHED CHECKS YOU MUST PROVIDE ALL AVAILABLE BANK
STATEMENTS FOR THE RELEVANT PERIOD SHOWING ALL DEPOSITS AND
WITHDRAWALS
OTHER RELEVANT RECORDS WOULD INCLUDE ALL AVAILABLE ONLINE
GAMBLING STATEMENTS AND PLAYER CARD STATEMENTS FROM ANY CASINOS
(If this information is not available, please obtain and provide any other information to confirm
the withdrawals and/or other transactions set out above)

6. OTHER IMPACTS AND LOSSES/EXPENSES FROM MIRAPEX®
a)
Did you, at any time while taking Mirapex®, acquire any non-gambling impulse control
disorders (e.g.: compulsive eating, shopping, hyper-sexuality, compulsive body picking, etc.):

b)
If you answered "Yes" to (a), please describe the nature of this behaviour in detail (attach
additional pages if necessary):
c)
Do you believe that Mirapex® impacted your ability to earn an income in any way?
MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP) If you answered "Yes", please describe how Mirapex® impacted your ability to earn an income
and estimate the amount of income you believe you have lost as a result (attach additional pages
if necessary):

d)
Did you suffer any other expenses (e.g.: medical, legal, etc.) as a result of any impact that you
believe Mirapex® has had on you? Yes No
If you answered "Yes", please describe these expenses and provide the total amount of these
expenses (attach additional pages if necessary):

YOU MUST OBTAIN AND PROVIDE ALL DOCUMENTS CONFIRMING THESE LOSSES
AND/OR EXPENSES
(If this information is not available, please obtain and provide any other information to confirm
these losses and/or expenses)

7. KNOWLEDGE OF MIRAPEX® SIDE EFFECTS
a).
To the best of your recollection, when did you first become aware of a possible relationship
between Mirapex and compulsive behaviour? ____________

b).
How did you first become aware of a possible relationship between Mirapex and compulsive
behaviour? (please check one)

i) Newspaper, magazine, televisions or radio:
If you answered yes to (i) please identify the publication: ______________ Mirapex package insert or other medical literature: If you answered yes to (ii) please identify the publication: ______________ If you answered yes to (iii) please identify the medical professional and briefly describe what you were told: ____________________________________ MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP)
c)
Please describe the nature of any treatment or advice you have received for the compulsive
activities you have identified in this Questionnaire (in addition to any treatment that you
described at section 4(f) of this Questionnaire).

8. PHYSICIAN AND OTHER MEDICAL INFORMATION
a. Who is your family doctor?
Name ___________________________________________________________________
Mailing Address of Physician ________________________________________________ Phone Number of Physician __________________________________________________
b. Who is the doctor that prescribed Mirapex® to you?
Name ___________________________________________________________________
Type of Specialty __________________________________________________________ Mailing Address of Physician ________________________________________________ Phone Number of Physician __________________________________________________
c. What other doctor(s) and/or health professional(s) prescribed Mirapex® to you, or has
awareness of its impacts on you?
Name ___________________________________________________________________
Type of Physician or Health Professional________________________________________ Mailing Address of Physician ________________________________________________ Phone Number of Physician __________________________________________________ Name ___________________________________________________________________ Type of Physician or Health Professional________________________________________ Mailing Address of Physician ________________________________________________ Phone Number of Physician __________________________________________________ MIRAPEX® QUESTIONNAIRE
(Ontario Class Action No. 05-CV-288851CP) THESE DOCTORS WILL BE ASKED TO PROVIDE YOUR MEDICAL RECORDS IN
ORDER TO HELP ESTABLISH YOUR CLAIM.
9. WHAT ELSE WOULD YOU LIKE TO TELL US?
Please add any further information that you believe we should know about the impact you
believe Mirapex® has had on your life (attach additional pages as necessary)
I HEREBY REPRESENT AND WARRANT THAT THE INFORMATION PROVIDED IN
AND WITH THIS FORM IS THE SWORN TRUTH AND IS COMPLETE AND CORRECT,
AND I HEREBY AUTHORIZE TR AND/OR ITS AGENTS TO RELEASE THE SAID
INFORMATION TO BICL.


Signature of Class Member

Source: http://www.thomsonrogers.com/sites/default/files/mirapex-negotiation-process-questionnaire.pdf

Troy band

TROY BAND Student Medical and Treatment Authorization Form Student’s Name_____________________________________________Age________________ (first) (last) (m.i.) Birthdate__________________________________Male________Female__________________ Home Address__________________________________________________________________ City_____________________________________________State__________Zip Co

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