.                DES QUESTIONNAIRE

PERSONAL DATA:

   1. NAME:



   2. ANY OTHER NAME USED (include dates when used):




   3. CURRENT ADDRESS:





   3a. EMAIL ADDRESS:


   4. TELEPHONE NUMBERS:
          Home:
          Work:
          Spouse (W):

   5. SOCIAL SECURITY NUMBER:


   6. OCCUPATION:


   7. YOUR DATE OF BIRTH:


   8. YOUR PLACE OF BIRTH (Hospital, City and State):



   9. SPOUSE:
          SPOUSE'S OCCUPATION:
          SPOUSE'S SOCIAL SECURITY NUMBER:
          SPOUSE'S PLACE OF BIRTH:




10.  DATE(S):
           MARRIED:(if separated or divorced list names of all spouses
           and dates of marriages and divorces for both of you)




INJURIES/DAMAGES:


  11. PREGNANCY HISTORY:

          NUMBER OF PREGNANCIES: (Dates, Outcome)




          NUMBER OF LIVE BIRTHS: (Dates with Full Names)




          MISCARRIAGES OR ABORTIONS: (Dates)



  12. YOUR KNOWN PHYSICAL DES-RELATED INJURIES:

          ANATOMICAL INJURY     DX DR    DATE DX    ADDRESS     PHONE







  13. IF THE INJURY IN QUESTION IS A PREMATURE DELIVERY, PLEASE ANSWER
        THE FOLLOWING:

          a. WHAT DID THE DOCTOR ATTRIBUTE THE PREMATURITY TO?



          b. HAS YOUR CHILD BEEN DIAGNOSED AS HAVING A PARTICULAR
             CONDITION?  IF SO, DESCRIBE.




           c. LIST YOUR CHILD'S DOCTORS, INCLUDING PEDIATRICIANS AND
              SPECIALISTS WITH THEIR ADDRESSES AND TELEPHONE NUMBERS:



          d. GIVE YOUR BEST ESTIMATE OF EXPENSES INCURRED TO DATE:
             (e.g., hospital bills, surgical bills)




  14. FERTILITY STATUS:


  15. HAVE YOU ADOPTED OR ARE YOU PRESENTLY ADOPTING: (If yes, list the
        date of adoption, adoption agency or referral source, etc.)



YOUR MEDICAL HISTORY:

  16. CURRENT TREATING PHYSICIAN(S):  (include address and phone number;
       continue on separate sheet if necessary)




  17. DATE OF MOST RECENT GYNECOLOGICAL EXAM:


  18. HAVE YOU EVER UNDERGONE AN HSG (HYSTEROSALPINGOGRAM)? (i.e., a
        procedure where dye is injected through the cervix into the uterus and tubes to look for
        abnormalities of those organs.  If so, please give us the name of the doctor, the date of the
        test and where the test was done)



  19. LIST NAMES, ADDRESSES AND TELEPHONE NUMBERS OF ALL OB/GYN 
      PHYSICIANS SEEN IN THE PAST:  (Please list dates seen and treatment received.
      Include health clinics or university clinics. Continue on a separate sheet if more space
      is required)





  20. LIST ANY INFERTILITY SPECIALIST CONSULTED: (give dates, address and
      phone if not already listed)





  21. OTHER RELEVANT MEDICAL HISTORY, ILLNESS, SURGERIES:  Include any
      psychiatric care or counselling you have received due to your DES injury.)

     DATE       TREATMENT                PHYSICIAN/HOSPITAL      ADDRESS








  22. BIRTH CONTROL HISTORY:  list all methods of birth control and the dates they were used.



DES EXPOSURE INFORMATION:


  23. WHEN DID YOU FIRST BECOME AWARE OF YOUR DES EXPOSURE?




  24. HOW DID YOU BECOME AWARE OF YOUR DES EXPOSURE?




  25. WHEN DID YOU FIRST LEARN THAT YOU COULD BRING SUIT AGAINST A
         PHARMACEUTICAL COMPANY? (list any previous attorney(s) seen)





  26. HOW DID YOU LEARN THAT YOU COULD BRING SUIT AGAINST A PHARMACEUTICAL
        COMPANY?




  27. WHO REFERRED YOU TO PATRICIA M. STANFORD?


FAMILY HISTORY:


  28. MOTHER'S NAME  (Including maiden name)



  29. ANY PREVIOUS NAME YOUR MOTHER USED DURING THE TIME OF PREGNANCY WITH
        YOU (when and where):



  30.MOTHER'S DATE OF BIRTH:
                           SOCIAL SECURITY NO..:



  31. MOTHER'S CURRENT ADDRESS



  32. MOTHER'S TELEPHONE NUMBER:	(H):
                                                             (W):

  33. STATE THE ADDRESS OF EACH RESIDENCE AT WHICH YOUR NATURAL MOTHER 
       RESIDED DURING THE TWELVE MONTHS PRIOR TO YOUR BIRTH:







  34. FATHER'S NAME:
        FATHER'S SOCIAL SECURITY NUMBER:


  35. FATHER'S CURRENT ADDRESS:



  36. FATHER'S TELEPHONE NUMBERS: (H):
                                                               (W):


  37. SIBLINGS (NAME, DATE OF BIRTH, EXPOSED TO DES?):

       NAME              DATE OF BIRTH           EXPOSED TO DES     UNEXPOSED







  38. FOR EACH SIBLING ABOVE LIST THE MARITAL STATUS AND THE NUMBER OF
        PREGNANCIES AND CHILDREN:




INFORMATION ON DES DOSAGE:


  39. MOTHER'S DES DOSAGE:


  40. MOTHER'S RECOLLECTION OF MEDICATION INGESTED DURING PREGNANCY WITH
        YOU:

                    NAME OF MEDICATION       COLOR        SIZE        INSTRUCTIONS




  41. IF MOTHER IS DECEASED, IS THERE ANY OTHER FAMILY MEMBER (i.e., husband, sister,
        etc.) THAT MIGHT RECALL ANYTHING ABOUT THE PRESCRIPTION OR THE ACTUAL
        MEDICATION INGESTED?  IF SO, LIST NAME, ADDRESS, TELEPHONE NUMBER,
        RELATIONSHIP.



  42. REASON MOTHER WAS GIVEN FOR TAKING DES: (list any previous miscarriages with the
        dates.)





  43. DATE OF LAST MENSTRUAL PERIOD FOR MOTHER'S PREGNANCY WITH YOU:



  44. PERIOD OF TIME TAKEN: (list month/day/year started to month/day/year stopped as close as
        possible)



  45. WHERE TAKEN:  (home, doctor's office, hospital)


  46. NAME, ADDRESS, TELEPHONE NUMBER OF PHYSICIAN WHO PRESCRIBED DES: (State
        whether doctor is known to be deceased)




  47. DRUG NAME ON RECORDS:



  48. NAME OF PHARMACY(IES) AND ADDRESS(ES) WHERE PRESCRIPTION FOR DES WAS
        FILLED. IF UNKNOWN, GIVE AS MUCH INFORMATION AS KNOWN.




  49. NAME(S), ADDRESS(ES), TELEPHONE NUMBER(S) OF ANY PHARMACY EMPLOYEES
        YOU OR ANY MEMBER OF YOUR FAMILY MIGHT KNOW:




  50. IF KNOWN, STATE MANUFACTURER OF DES PRESCRIBED TO MOTHER:



  51. DO YOU HAVE ANY ADDITIONAL INFORMATION REGARDING THE PRESCRIPTION OR
        DRUG TAKEN?




  52. NAME(S) AND ADDRESS(ES) OF EACH PHYSICIAN CONSULTED BY YOUR MOTHER FOR
        ANY REASON DURING HER PREGNANCY WITH YOU AND THE REASON FOR SUCH
        CONSULTATION(S):






  53. NAME(S) AND ADDRESS(ES) OF ANY HOSPITAL OR OTHER MEDICAL FACILITY AT
        WHICH YOUR MOTHER WAS TREATED FOR ANY REASON DURING HER PREGNANCY
        WITH YOU AND THE REASON FOR SUCH HOSPITALIZATION:






  54. NAME(S) AND ADDRESS(ES) OF EACH AND EVERY PHYSICIAN ATTENDING YOUR
        MOTHER IN ANY HOSPITAL OR OTHER MEDICAL FACILITY: