IN RE: PHILIPS RECALLED CPAP, BI- LEVEL PAP, AND MECHANICAL VENTILATOR PRODUCTS LIABILITY LITIGATION | ) ) ) ) | Master Docket: Misc. No. 21-1230 MDL No. 3014 |
Claimant MDL-C Plaintiff Identification No. | Claimant First Name | Claimant Last Name |
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IN RE: PHILIPS RECALLED CPAP, BI- LEVEL PAP, AND MECHANICAL VENTILATOR PRODUCTS LIABILITY LITIGATION This Document Relates to: Personal Injury Claimants and Potential Claimants | Master Docket: No. 21-mc-1230-JFC MDL No. 3014 |
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IN RE: PHILIPS RECALLED CPAP, BI- LEVEL PAP, AND MECHANICAL VENTILATOR PRODUCTS LIABILITY LITIGATION This Document Relates to: Personal Injury Claimants and Potential Claimants | Master Docket: No. 21-mc-1230-JFC MDL No. 3014 |
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PRIM ARY COU NSEL | PRIM ARY COUN SEL EMAI L ADDR ESS | CLAI MANT NAME (FIRS T) | CLAI MANT NAME (LAST) | S S N | CL AI MA NT EM AIL AD DR ESS | CLAI MAN T ADDR ESS | DOB mm/d d/year | Cour t Of Filin g | Dock et Num ber | MDL -C Num ber | QUALI FYING INJUR Y |
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IN RE: PHILIPS RECALLED CPAP, BI- LEVEL PAP, AND MECHANICAL VENTILATOR PRODUCTS LIABILITY LITIGATION This Document Relates to: Personal Injury Claimants and Potential Claimants | Master Docket: No. 21-mc-1230-JFC MDL No. 3014 |
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CLAI MANT NAME (FIRST ) | CLAI MANT NAME (LAST) | S S N | CLAI MANT EMAI L ADDR ESS | CLAI MANT PHON E NUMB ER | CLAI MANT ADDR ESS | DOB mm/dd /year | Co urt Of Fili ng | Doc ket Num ber | MDL- C Numb er (if applic able) | QUALI FYING INJURY |
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Your Address | Represented Person’s Address (Respironics Device User/Plaintiff’s Last Known Address) | Capacity in which you are representing the individual or estate | Relationship to the Represented Person (Respironics Device User/ Plaintiff) |
Case Name: | |
Case Number: |
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Respironics | Respironics | Approximate | How much | Reason for | Name and Address of | Name and |
Device | Device | Purchase | of the total | Use of the | Health Care Provider(s) | address of |
Model | Serial | Date of | purchase | Respironics | who | the DME |
Name and | Number | Respironics | price of the | Device | prescribed/recommended | that |
Number | Device | Respironics | the use of the | provided | ||
Device did | Respironics Device | the | ||||
you pay? | Respironics | |||||
Device | ||||||
Respironics | What date did | In general, how | In general, how | Did you use | If yes daytime use, |
Device Name | you start using | many nights per 7 | many hours per | the | approximately how |
and Serial | the Respironics | day week do/did | night do/did you | Respironics | many hours per day |
Number | Device? | you use the | use the | Device during | do/did you use the |
Respironics | Respironics | the daytime? | Respironics Device? | ||
Device? | Device? | (Y/N) | |||
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Dates of residence | Location (city and state) |
Respironics Device Name and Serial Number | Where was the Respironics Device stored? |
Have you paused/stopped using the Respironics Device? | When and for what period of time? |
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Respironics Device Name and Serial Number | Have you or anyone on your behalf ever cleaned your Respironics Device(s)? | How did you clean the Respironics Device(s) | What products did you use to clean the Respironics Device(s)? (Please identify all products, including any products |
advertised by third parties as CPAP cleaning devices.) | |||
Accessory Name | Accessory Type | From Whom Did You Acquire the Accessory? | When Did You Acquire the Accessory? |
1 |
Current Address | Date you moved there |
Most Recent Former Address | Dates during which you resided there (approximately) |
Current Employer | Address | Phone Number |
1 |
Approximate Dates you were out of work | Employer at the time | Health Condition |
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Height | Weight |
Condition Experienced or Diagnosed | Yes | No | Do Not Know | Treating Physician |
Acute Inhalation Injury | ||||
Acute Respiratory Failure | ||||
Allergies or Allergic Reaction | ||||
Asthma | ||||
Atrial Fibrillation | ||||
Bronchitis | ||||
Cancer | ||||
Chronic Obstructive Pulmonary Disease | ||||
Chronic Kidney Disease | ||||
Chronic Sinusitis | ||||
Heart Failure |
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Lung Injury or Damage | ||||
Nasal Turbinate Hypertrophy |
1 |
Pneumonia | ||||
Pulmonary Fibrosis | ||||
Sarcoidosis | ||||
Sleep Apnea | ||||
Recurrent Esophageal Candida | ||||
Respiratory Infection or Failure |
Type of Cancer | Treating Physician (if different than above in Question 28) |
Sleep Disorder | Treatment to address the disorder |
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Name | Address | Approximate Dates/Years of Visits | Reason(s) for Visit or Specialty |
Name | Address | Approximate Admission Date(s) | Reason(s) for Visits |
Insurer Carrier | Policyholder | Policy Number | Approximate Dates of Coverage | Includes DME Coverage (Yes/No/Don’t Know) |
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Medication | Condition for | Prescriber | Date of First | Medication |
Name | Prescription | Name and | Prescription | prescribed for |
Address | alleged injury | |||
Yes/No? | ||||
Tobacco Product | Date Started | Date Ceased (or Ongoing) | Frequency of Use |
Cigarettes | |||
E-Cigarettes/Vape Pens | |||
Cigars | |||
Pipes (including Hookah) | |||
Chewing Tobacco | |||
Snuff | |||
Any other Nicotine Product | |||
Marijuana |
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Name of Employer | Address and Telephone Number | Dates of Employment | Type of Business and Position |
2 |
Physical Injury | Approximately | Is the injury or | When were | Who diagnosed | Where was the |
or Illness | when the | illness | you diagnosed | the injury or | injury or illness |
symptoms began | continuing? | with this | illness? | diagnosed? | |
injury or | |||||
illness | |||||
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