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Hilliard Law
Allergan Additional Questions
Additional Questions Allergan
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Case Number
First Name
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Last Name
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SSN
Please indicate if you have experienced the following physical injuries (select all that apply)
ALCL
Scarring and Disfigurement
Diagnostics and Explant
Reconstruction
Hospitalization
Infection
Disability
Chronic Pain
Seroma
Pain prior to explant procedure
Rashes
Itching
Swelling
Asymmetry of Breasts
Capsular Contracture
Heat Sensation
Please indicate whether you have experienced new onset or aggravation of any of the following conditions as a result of your mental anguish related to the implants (select all that apply)
Depression
Anxiety
Panic disorder
PTSD
Chronic insomnia
Significant weight loss or weight gain
Ulcer
Irritable bowel and Crohns disease
Chronic headache
Chronic gastrointestinal upset or reflux
Diarrhea vomiting and nausea on an ongoing basis
Phone
This field is for validation purposes and should be left unchanged.
