Fleet Lawsuit Questionnaire

Acute Phosphate Nephropathy Questionnaire/Screening Tool

Thank you for your interest in having Pritzker | Ruohonen represent you in your claim for kidney damage resulting from use of Fleet or Visicol (oral sodium phosphate bowel preparation). In order to assist you, we ask that you answer the 18 questions below AS BEST YOU CAN and email, fax, or mail them to our office for review by an attorney at Pritzker | Ruohonen. If you prefer to speak with an attorney before answering any questions on the questionnaire, please contact us directly toll-free at 1-888-377-8900. We will be happy to speak with you on the phone and help you with the questionnaire.

To email your answers, please send them to the following address:

info@pritzkerlaw.com

To mail your answers, please send them to the following address:

Attention: Fred Pritzker
Pritzker | Ruohonen & Associates, P.A.
Plaza VII, Suite
45 South Seventh Street
Minneapolis, MN 55402

To fax your answers, please use the following number:

612-338-0104 (fax)

Throughout the questionnaire OSPS is used to mean oral sodium phosphate solution, generally Fleet or Visicol.

1. Name of patient: _________________________________

2. Age of patient at time ARF (acute renal failure) recognized:
_________________________________________________

3. How was the patient advised to purchase and use OSPS (e.g. received printed handout from office of doctor performing colonoscopy):
_________________________________________________

4. When was the OSPS purchased: ______________________

5. What was the name of the store or pharmacy at which the OSPS was purchased:
_________________________________________________

6. What evidence is there of OSPS purchase (i.e. sales receipts, the empty box or container, credit card receipt, frequent shopper card):
__________________________________________________

7. What was the date on which the OSPS (Fleet or Visicol) was taken: _________

8. Was the OSPS (Fleet or Visicol) used as recommended? Y or N (circle one).
If yes, explain: _______________________________________
(Note: We will need any printed instructions or other written material about the purchase or use of OSPS that were given to the patient.)

9. Was there a baseline (pre-ARF; pre-use of OSPS) creatinine level? Y or N (circle one).
If so, what was it: ____________________________________

(Note: Our attorneys will need to have appropriate medical records that document when the colonoscopy procedure was done, where it was done, and by whom it was performed.)

10. When did the patient first develop symptoms consistent with ARF?
__________________________________________________
(Note: We will need the lab results to find information regarding urine protein, serum calcium, and serum phosphorus.)

11. Was a kidney biopsy done? Y or N (circle one). If yes:

When was it done?______________________________
Where was it done?______________________________

(Note: Our attorneys will need all medical records relating to the kidney biopsy to determine if the biopsy indicated acute and/or chronic tubular injury with abundant tubular calcium phosphate deposition. We will also review the biopsy medical records to determine what the creatinine level was at time of biopsy.)

12. Was the patient using any of these classes of medications before use of OSPS (Fleet or Visicol) which could result in inadequate hydration (ACE-I, ARB, diuretics and NASIDS all exacerbate volume depletion)? Please circle any of the following medications the patient was using before use of OSPS (Fleet or Visicol):

ARB. The following is a list of currently available ARBs: candesartan (ATACAND), eprosartan (TEVETAN), irbesartan (AVAPRO), telmisartan (MYCARDIS), valsartan (DIOVAN), and losartan (COZAAR).
ACE Inhibitors: captopril (Capoten), benazepril (Lotensin), enalapril (Vasotec), lisinopril (Prinivil, Zestril) fosinopril (Monopril), ramipril (Altace), perindopril (Aceon), quinapril (Accupril), moexipril (Univasc), and trandolapril (Mavik).

15. Did the patient have a history of Hypertension (high blood pressure) before use of OSPS?
(Note:  We will need medical records relating to the hypertension.)

16.  Pre-existing chronic kidney disease? Y or N (circle one).
(Note:  We will need medical records relating to the pre-existing chronic kidney disease.)

17.  Did the patient have a history of diabetes before use of OSPS? Y or N (circle one).
(Note:  We will need medical records relating to the diabetes.)

18. Did patient have evidence of pre-existing electrolyte disorders? Y or N (circle one).
(Note: We will need lab records showing pre-existing electrolyte disorder (check labs prior to use of OSPS). Normal levels of electrolytes are:

Sodium. 135-145 mEq/L (serum)
Potassium. 3.5-5.5 mEq/L (serum)
Calcium. 8.8-10.4 mg/dL (total Ca; serum); 4.7-5.2 mg/dL (unbound Ca; serum)
Magnesium. 1.4-2.1 mEq/L (plasma)
Chloride. 100-108 mEq/L (serum)
Phosphate. 2.5-4.5 mg/dL (plasma; adults))

FLEET LAWSUIT INFORMATION - PRITZKER | RUOHONEN, A PREMIER PERSONAL INJURY LAW FIRM, IS MAKING PREPARATIONS FOR VISICOL AND FLEET LAWSUITS. IF YOU OR A FAMILY MEMBER HAS EXPERIENCED KIDNEY DAMAGE, INCLUDING KIDNEY FAILURE, AFTER THE USE OF FLEET OR VISICOL, FILL OUT THIS FLEET LAWSUIT QUESTIONNAIRE AS BEST YOU CAN. YOU DO NOT HAVE TO ANSWER EVERY QUESTION. IF YOU HAVE ANY QUESTIONS ABOUT A VISICOL OR FLEET LAWSUIT, PLEASE CALL TOLL-FREE AT 1-888-377-8900.

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