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
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Zip Code

Please provide the best method and times to contact you:

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

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

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

Name(s) of all antidepressants taken:

Age of patient when antidepressant(s) prescribed:

What condition was this medication prescribed to treat?

Did patient become violent while taking antidepressant(s)?
Yes
No

Was suicide attempted after taking antidepressant(s)?
Yes
No

Did attempted suicide result in death?
Yes
No

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

If you have stopped taking Effexor, or have tried to stop taking Effexor, have you experienced withdrawal side effects?
Yes
No

Please further describe side effects:

Other Info:

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