Schedule Consultation: Drug Injury Interview & Questionnaire

Drug Injury Interview Screen Questionnaire

First & Last Name

Email Address

What happened to you (or your loved one)?

What drug do you believe is responsible for this?

Why do you believe this drug is responsible for this?

What impact did the drug injury have?

Was the drug injury partially explain by other factors? If yes, please explain why you still believe these factors do not account for the drug injury

Are you willing to have this interview publicly available

Yes No