Fluoroquinolone Lawsuit Registry

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In order to gauge whether there is a sufficient number of interested sufferers committed to being represented in a suit, law firms typically request those who are suffering to provide information on their cases by a deadline. They then count the number of completed responses. One law firm has requested that we collect information from those who have been affected by Fluoroquinolones. The information below will be shared with that law firm. You may also indicate if we may contact you via email in the future if other law firms express interest in fluoroquinolone long-term adverse effects. You may still sign up as we proceed through the wind-up process with that firm or the presentation and consideration of our case to other firms.

Your name *

Enter your first and last name.

Email Address (This will only be used by the currently requesting law firm to contact you unless you specify below that we may contact you about other law firms in the future.) *

Enter an email address that you check regularly so that you may be contacted for further requested information such as your story or your list of symptoms.

May we contact you in the future if other law firms express interest in collecting information or stories from those suffering fluoroquinolone ADRs? *

Law firms usually want to guage whether there is enough interest to file a lawsuit by the number of responses they can receive in a short period, such as 5 days. In order show interest, we would like to be able to contact as many FQ ADR sufferers as possible.

Yes, it's okay to email me if other law firms are interested

No, I only wish to participate with the current firm only

Phone Number (This will only be used by the law firm to contact you.) *

Enter your phone number. This will only be used for the law firm to contact you.

How long ago did you take your last fluoroqinolone (in months)? *

Please enter the number of months that have passed since you took your last fluoroquinolone.

What was the last fluoroqinolone you took (if you took a combination, specify the combination in "other"? *

Ciprofloxacin (Cipro)

Levofloxacin (Levaquin)

Moxifloxacin (Avelox)

Both Ciprofloxacin (Cipro) and Levofloxacin (Levaquin)

Other:

What is your #1 worst symptom?

What is your #2 worst symptom?

What is your #3 worst symptom?

Which of the following Central Nervous System symptoms have you experienced?

Insomnia

Panic/Anxiety

Brain Fog (impaired thinking)

Memory loss (including impaired short term memory)

Difficulty remembering words (Aphasia)

Confusion

Abnormal dreams

Headaches

Depersonalization (feeling of watching self from outside)

Depression

Thoughts of suicide

Agitation / personality changes

Hallucinations

Seizures

Inability to process all visual input being received at once

Which of the following Peripheral Nervous System symptoms have you experienced?

Feelings in arms or legs of: tingling, prickling, pins&needles, numbness, bugs running on skin, water trickling, fabric moving, buzzing, pressure, squeezing, electrical zaps, shocks, or burning skin (Dysaesthesia)

Feelings in face, head, lips, or teeth of: squeezing, pressure, shocks, tingling, buzzing, etc.

Feelings on the trunk of the body of: waves, tingling, prickling, pins&needles, or numbness, bugs running on skin, water trickling, fabric moving, buzzing, pressure, squeezing, electrical zaps, shocks, or burning skin

Pain with normally non-painful touch or hypersensitivity to pain (Allodynia, Hyperalgesia)

Muscle twitching of a whole muscle body (Tremors)

Muscle twitching of small pieces of a muscle independently (Fasciculations)

Neuralgia (pain along nerve trunk lines)

Which of the following Autonomic Nervous System symptoms have you experienced?

Heart rhythm abnormalities or palpitations (including fast/slow/irregular heartbeat)

Breathing problems (including shortness of breath, feeling like lungs can't function well enough)

Digestive issues not treatable with probiotics or antibiotics (delayed gastric emptying, constipation, diarrhea unresponsive to probiotics and antibiotics)

Measured abnormal body temperature (not just feeling cold, must have been measured on a thermometer)

Low or high blood pressure or Postural Orthostatic Hypotension (POTS)

Sweating response inappropriate for environment (too little sweating or too much sweating for conditions)

Lightheadedness

Fainting

Loss of libido (males or females)

Dry eyes, dry mouth, or (during intercourse) dry vagina

For males, loss morning or nighttime erections

For males, testicular or prostate pain

Which of the following Vision symptoms have you experienced?

Eye focusing problems

Dry eyes

Retinal tears

Double vision (Diplopia)

Visual acuity decrease

Blurry or lost center of vision (Central scotomas)

Light sensitivity (overbright lights sensation)

Increased floaters

Black specks in vision

Drooping eyelids (Ptosis)

Which of the following categories of symptoms have you experienced (mark here even if you marked individual symptoms above)?

Central Nervous System

Peripheral Nervous System

Autonomic Nervous System

Vision

Thank you.

Thank you for showing your support for a lawsuit regarding fluoroquinolone adverse effects. Please click "Submit" below to complete submitting the form.

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