Mirena Class Action – questionnaire Name First Last Email Would you like our firm to send you e-mail updates regarding this proceeding and other class actions? Yes No When did you have the Mirena IUD inserted? In the weeks or months following insertion of the device were any steps taken to confirm proper insertion, such as conducting the string test, an ultrasound or an x-ray? Yes No If yes, which of those steps were taken?Did the Mirena Device migrate from your uterus? Yes No Was the Mirena device removed by a surgical procedure? Yes No If so, when was it removed? Did you suffer any other side effects from the device?Have you suffered any income loss or loss of earning capacity because of the side effects you experienced from Mirena? Yes No If so, please provide detailsHave any of your immediate family members (such as spouse, children, grandchildren, parents, grandparents, brothers and sisters) suffered because of your experience with Mirena? Yes No If yes, please provide detailsDo you have any additional comments you would like to make?