* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date you stopped taking this drug:

Date you started taking this drug:

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:

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