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Date you started taking this drug:

Date you stopped taking this drug:

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?

Did patient become violent during or after taking the drug?

Was suicide attempted?

Was hospitalization or institutionalization required after taking antidepressant(s)?

Did loved one commit suicide?

If patient did attempt or commit suicide, did patient ever attempt suicide previously?

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:

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Eliot Spitzer Warns `Arrogant` Glaxo

Sep 1, 2004 | www.business-standard.com

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