Paraquat Parkinson's
Qualification Survey

Step 1 of 36

Answer this short survey to see if you qualify for a legal case:

Are you calling on behalf of yourself or someone else?

Self

Someone else

Is the person you are inquiring for deceased?

Yes

When did your loved one pass away?

MM slash DD slash YYYY

Please provide their first and last name?

First Last

What is your relationship with the person?

Are you currently being represented by another law firm regarding this case?

Yes

Are they currently being represented by another law firm regarding this case?

Yes

Have you ever mixed, sprayed, applied, transferred, or worked in a paraquat manufacturing plant?

Yes

Have they ever mixed, sprayed, applied, transferred, or worked in a paraquat manufacturing plant?

Yes

Have you lived on a farm or worked where Paraquat was used?

Yes

Have they lived on a farm or worked where Paraquat was used?

Yes

Have you used any of the following products?

Gramoxone

Paraquat Concentrate

Blanco

Cyclone SL 2.0

Firestorm

Helmquat 3SL

Bonedry

Devour

Para-Shot 3.0

Parazone Weedmaster

Ortho-Paraquat

Unsure of herbicide sprayed

None

Have they used any of the following products?

Gramoxone

Paraquat Concentrate

Blanco

Cyclone SL 2.0

Firestorm

Helmquat 3SL

Bonedry

Devour

Para-Shot 3.0

Parazone Weedmaster

Ortho-Paraquat

Unsure of herbicide sprayed

None

When did you begin using Paraquat?

MM slash DD slash YYYY

When did they begin using Paraquat?

MM slash DD slash YYYY

How many days total were you exposed to Paraquat (NOTE: a “day” is any exposure on any particular day)?

Please enter a number greater than or equal to 0.

How many days total were they exposed to Paraquat (NOTE: a “day” is any exposure on any particular day)?

Please enter a number greater than or equal to 0.

Do you have a restricted use pesticide license or are you a certified pesticide applicator?

Pesticide license

Certified pesticide applicator

Both

None

Do they have a restricted use pesticide license or are they a certified pesticide applicator?

Pesticide license

Certified pesticide applicator

Both

None

Are you willing to sign a sworn Affidavit regarding your exposure to Paraquat?

Yes

Are they willing to sign a sworn Affidavit regarding their exposure to Paraquat?.

Yes

Have you been diagnosed with Parkinson’s disease?

Yes

Have they been diagnosed with Parkinson’s disease?

Yes

How old were you when diagnosed with Parkinson’s disease?

Please enter a number greater than or equal to 0.

How old were they when diagnosed with Parkinson’s disease?

Please enter a number greater than or equal to 0.

What was the date of the diagnosis?

MM slash DD slash YYYY

Has a DaTscan been performed (DaT is a tool used to confirm the diagnosis of Parkinson's disease)?

Yes

Have you suffered from any of the following Symptoms?

Tremors/Trembling

Balance Impairment

Sleep Disorders (includes early awakenings or sleep disturbances)

Rigidity

Bradykinesia (slowness of movement, slow gait, shuffling)

Difficulty Speaking (includes soft speaking)

Reduced Facial Expression (includes blank stare)

Spasms

Decreased Range of Motion (ROM)

Micrographia (small handwriting)

Difficulty Swallowing

Drooling

Paralysis

Fatigue

Anxiety

Dizziness

Amnesia

Confusion

Hallucination – General (seeing hearing or experiencing things others aren’t)

General Cognitive Impairment

Hallucination – Visual

Delusion (believing things that are not true)

Hallucination – Auditory

Apathy

Delirium

Stiffness

Have they suffered from any of the following Symptoms?

Tremors/Trembling

Balance Impairment

Sleep Disorders (includes early awakenings or sleep disturbances)

Rigidity

Bradykinesia (slowness of movement, slow gait, shuffling)

Difficulty Speaking (includes soft speaking)

Reduced Facial Expression (includes blank stare)

Spasms

Decreased Range of Motion (ROM)

Micrographia (small handwriting)

Difficulty Swallowing

Drooling

Paralysis

Fatigue

Anxiety

Dizziness

Amnesia

Confusion

Hallucination – General (seeing hearing or experiencing things others aren’t)

General Cognitive Impairment

Hallucination – Visual

Delusion (believing things that are not true)

Hallucination – Auditory

Apathy

Delirium

Stiffness

When did you begin experiencing these symptoms?

MM slash DD slash YYYY

When did they begin experiencing these symptoms?

MM slash DD slash YYYY

Have you been prescribed any of the following medications for your symptoms?

Amantadine

Apokyn (apomorphine hydrochloride injection)

Artane (trihexyphenidyl HCL)

Axilect (rasagiline)

Cogentin (benztropine)

Elepryl (selegiline)

KYNMOBI (Apomorphine hydrochloride)

Sinemet (levodopa)

Mirapex (pramipexole)

Neupro (Rotigotine Transdermal System)

Nourizanz (istradefylline)

Requip (ropinirole)

Xadago (safinamide)

Zelapar (Selegiline HCL orally disintegrating)

None

Have they been prescribed any of the following medications for their symptoms?

Amantadine

Apokyn (apomorphine hydrochloride injection)

Artane (trihexyphenidyl HCL)

Axilect (rasagiline)

Cogentin (benztropine)

Elepryl (selegiline)

KYNMOBI (Apomorphine hydrochloride)

Sinemet (levodopa)

Mirapex (pramipexole)

Neupro (Rotigotine Transdermal System)

Nourizanz (istradefylline)

Requip (ropinirole)

Xadago (safinamide)

Zelapar (Selegiline HCL orally disintegrating)

None

When did you begin taking the medication?

MM slash DD slash YYYY

When did they begin taking the medication?

MM slash DD slash YYYY

Are you currently residing outside of the U.S.?

Yes

We are just about finished evaluating your case. Can you please provide your first and last name:(Required)

First Last

Please provide your email address:(Required)

Please provide the best phone number to reach you:(Required)

Consent(Required)

I am asking that you contact me about my potential case. (more info)

Paraquat Parkinson's
Qualification Survey

Answer this short survey to see if you qualify for a legal case:

General

Practice Areas

Notices

Paraquat Parkinson's Qualification Survey

Answer this short survey to see if you qualify for a legal case:

General

Practice Areas

Notices

Paraquat Parkinson's
Qualification Survey