Congenital heart abnormality or condition Congestive failure or cardiomyopathy Coronary artery disease or other heart disease Deep Vein Thrombosis (DVT) Enlarged heart/cardiomegaly attack (or myocardial infarction [MI]); silent MI Hypertension or high blood pressure; Pulmonary Embolism (PE) Seizure disorder or epilepsy Any Stroke: ischemic or hemorrhagic; hemorrhage; transient ischemic attack (TIA) Venous thromboembolism (VTE) If you answered to question G, then provide the information requested below: “yes”, Approx. Dates or Health Care Condition Treatment Received Years of Provider Treatment/Visits Are you are claiming that you suffered from a stroke, transient ischemic attacks, clots, venous thromboembolism, deep vein thrombosis, or a pulmonary embolism as a result of your treatment with TRT? Yes _____ No _____ Are you are you claiming that you suffered from a heart attack, myocardial infarction, or any other heart-related condition as a result of your treatment with TRT? Yes _____ No _____ If you answered to questions I or J, then provide the information requested below “yes”, with regard to all treatment received by you in the last ten (10) years for any of these
Congenital heart abnormality or condition Congestive failure or cardiomyopathy Coronary artery disease or other heart disease Deep Vein Thrombosis (DVT) Enlarged heart/cardiomegaly attack (or myocardial infarction [MI]); silent MI Hypertension or high blood pressure; Pulmonary Embolism (PE) Seizure disorder or epilepsy Any Stroke: ischemic or hemorrhagic; hemorrhage; transient ischemic attack (TIA) Venous thromboembolism (VTE) If you answered “yes”, to question G, then provide the information requested below: Condition Health Care Provider Treatment Received Approx. Dates or Years of Treatment/Visits Are you are claiming that you suffered from a stroke, transient ischemic attacks, clots, venous thromboembolism, deep vein thrombosis, or a pulmonary embolism as a result of your treatment with TRT? Yes _____ No _____ Are you are you claiming that you suffered from a heart attack, myocardial infarction, or any other heart-related condition as a result of your treatment with TRT? Yes _____ No _____ If you answered “yes”, to questions I or J, then provide the information requested below with regard to all treatment received by you in the last ten (10) years for any of these
Amended%20PFS.DOCX