To the best of your knowledge, have you suffered from any of the following: Indicate whether Sought condition occurred Medical Condition treatment pre-implant, for? implant or both (explain, if necessary) Yes ___ Yes ___ Adhesions Pre ___ Post ___ No ___ No ___ Bleeding or Clotting Disorders Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If please specify Yes, disorder: Yes ___ Yes ___ Bowel Obstruction Pre ___ Post ___ No ___ No ___ Yes ___ Yes ___ Bowel Perforation Pre ___ Post ___ No ___ No ___ Cancer Yes ___ Yes ___ Pre ___ Post ___ If Yes, please specify No ___ No ___ type: Yes ___ Yes ___ Chronic Constipation Pre ___ Post ___ No ___ No ___ Collagen Yes ___ Yes ___ Pre ___ Post ___ Disorder/Deficiency No ___ No ___ Connective Tissue Disorder Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If Yes, please specify disorder: Crohn’s Disease, Irritable Bowel Syndrome, Ulcerative Colitis, or Chronic Diarrhea Yes ___ Yes ___ Pre ___ Post ___ No ___ No ___ If Yes, please specify which condition and treatment prescribed:
To the best of your knowledge, have you suffered from any of the following: Medical Condition Sought treatment for? Indicate whether condition occurred pre-implant, or both (explain, if necessary) Adhesions Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Bleeding or Clotting Disorders If Yes, please specify disorder: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Bowel Obstruction Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Bowel Perforation Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Cancer If Yes, please specify type: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Chronic Constipation Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Collagen Disorder/Deficiency Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Connective Tissue Disorder If Yes, please specify disorder: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ Crohn’s Disease, Irritable Bowel Syndrome, Ulcerative Colitis, or Chronic Diarrhea If Yes, please specify which condition and treatment prescribed: Yes ___ No ___ Yes ___ No ___ Pre ___ Post ___ implant
ColoplastPlaintiffProfileForm.docx