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First Name

Last Name

Address:

Phone:

Other number:

Date of Birth

Gender? Male Female

When where you first prescribed Crestor?

When did you stop taking Crestor?

Have you ever been hospitalized for symptoms, or conditions related to your having taken Crestor?
Yes No

What symptoms or conditions do you have today?  

Have you been diagnosed with rhabdomyolysis?
Yes No

If yes, Date diagnosed

Have you been diagnosed with kidney complications or experienced kidney failure?
Yes No

If yes, Date experienced

Have you had a kidney transplant because of Crestor?
Yes No

If yes, Date of transplant

Have you been diagnosed with liver problems or liver failure?
Yes No

If yes, Date diagnosed

Additional Comments: