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   * Last Name 

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Date you started taking this drug:

Date you stopped taking this drug:

What condition was this medication prescribed to treat?

What additional medications were you taking at the time?

Did Lariam appear to cause depression?Yes
No

Did Lariam appear to cause other psychological effects?Yes
No

Was suicide attempted?Yes
No

Did loved one commit suicide?Yes
No

Was a Psychiatrist/Psychologist ever seen before taking this drug?Yes
No

If yes, please describe psychological or psychiatric treatment:

Please further describe side effects:

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