* First Name
* Last Name
-U.S. Virgin Islands-
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?YesNo
Did Lariam appear to cause other psychological effects?YesNo
Was suicide attempted?YesNo
Did loved one commit suicide?YesNo
Was a Psychiatrist/Psychologist ever seen before taking this drug?YesNo
If yes, please describe psychological or psychiatric treatment:
Please further describe side effects:
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