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Name of Injured Party*:

Date of Birth:

Address:

City*:

State*: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip:

Email Address*:

Home Phone:

Work Phone:

Submitter (if Different): Relationship

Submitter's Phone:

Diagnosed with:         
Diabetes:  Date:

Hyperglycemia:  Date:

Ketoacidosis:  Date:

Pancreatitis:  Date:

Date of Death:  
Cause of Death

Other Symptoms:

Why taking Zyprexa:

Dates took Zyprexa and dosage:

Prescribing Physician:

Prescribing Pharmacy:

Treating Psych:

Family Physician:

Endocrinologist/Diabetes physician:

Personal and family history of Diabetes:

Other Comments: