Date of Birth

Gender

Male

Female

Social Security Number: (Last four digits are ok if uncomfortable, but may need full SS# if we take their case)

When (approximately) did you begin using your CPAP/BiPAP device(s)?

Select Philips CPAP/BiPAP/Ventilator device:

Continuous Ventilator, non-life supporting: DreamStation ASV DreamStation ST, AVAPS SystemOne ASV4 C-Series ASV C-Series S/T and AVAPS OmniLab Advanced+Noncontinuous Ventilator: SystemOne (Q-series) DreamStation DreamStation Go Dorma 400 Dorma 500 REMstar SE AutoContinuous Ventilator: Trilogy 100 Trilogy 200 Garbin Plus, Aeris, LifeVentContinuous Ventilator, Minimum Ventilatory Support, Facility Use: A-Series BiPAP V30 AutoContinuous Ventilator, Non-Life Supporting: A-Series BiPAP A40 A-Series BiPAP A30

Who is the manufacturer and what model name and number of your CPAP/BiPAP device(s)? (Note: 2nd Generation DreamStation is not affected by recall, RESMED machines are not part of this Mass Tort)

Are you experiencing Health Issues from your CPAP/ BiPAP

yesNo (if no, let them know they will be a pass at this time, but they are automatically part of the greatter class action suite against Philips for the machines themselves, we are looking to help those whose health is affected. They can hold onto our number heaven forbid anything surfaces, but to keep seeing their Doctor and consider themslves amoung the lucky.Unsure

If Yes, When after using your CPAP/BiPAP did you begin to notice problems?

Have you stopped using your CPAP/BiPAP? if yes when?

have you been notified of the recall? how?

Who prescribed you your CPAP/BiPAP, (Physician Name, Hospital, Address & Phone)

Where did you obtain the CPAP/BiPAP device(s)? (Name and Address of Medical Supply Company)

Did you receive recall notice? When?

What temperature/humidity settings have you used with your CPAP/BiPAP device(s)?

Why was device prescribed?

Obstructive Sleep Apnea/Sleep Related Breathing DisordersPremature BirthCOPDObesity Hypoventilation SyndromePneumoniaAsthmaNeurological Disease that Disturbs BreathingCardiopulmonary Disorder

Why was device prescribed? Other reason?

Since device use, have you been diagnosed with any of the following:

Lung CancerLiver CancerKidney Cancer, Papillary Renal CancerBladder CancerBrain CancerBreast CancerBlood Cancer, LeukemiaLymphatic Cancer, Non-Hodgkin’s LymphomaNasal CancerProstate Cancer (age 65 or under at diagnosis)Rectal CancerStomach Cancer

Describe your injury(ies) and or any diagnosis's. (Again, if not injured, tell them to consider themselves to be among the lucky, keep seeing their Doctor, and contact us if anything changes, but they will be contacted abount their machine if they registered with Philips on the notice)

When did this happen?

Insurance companies involved?

Smoking History

Current Smokerformer smokerNon-smoker

Smoking history II (years you smoked and how much) i.e. 3 years half a pack a day 2 years a pack a day and so on...

height

weight

Are you Diabetic?

Type IType IIN/A

Have you spoke to any other attorneys? if so what were the results of those conversations, and who did you speak to?

Intake Coordinators Initials (Phone Intake operator's use only)

ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

THANK YOU