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 started taking the drug (mm-yyyy):

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

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:

Other Info:

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