Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
-Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-

Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

Age of patient when antidepressant(s) prescribed:

What condition was this medication prescribed to treat?

What additional medications were you taking at the time?

Did patient hurt themselves during or after taking the drug?
Yes
No

Did patient become violent during or after taking the drug?
Yes
No

Was suicide attempted?
Yes
No

Was hospitalization or institutionalization required after taking antidepressant(s)?
Yes
No

Did loved one commit suicide?
Yes
No

If patient did attempt or commit suicide, did patient ever attempt suicide previously?
Yes
No

If patient did commit suicide, what was the method of suicide?

Please describe violent or suicidal behavior:

If you ever tried to stop taking Paxil and experienced withdrawal, please describe the withdrawal side effects:

Please further describe side effects:

Other Info:

No Yes, I agree to the Parker Waichman Alonso LLP disclaimers.Click here to review all.

Yes, I would like to receive the Parker Waichman Alonso LLP monthly newsletter, InjuryAlert.