* First Name 

   * Last Name 

   * Email 

Phone 

Cell Phone 

Street Address 

Zip Code 

City 

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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?Yes
No

Did patient become violent during or after taking the drug?Yes
No

Was suicide attempted?Yes
No

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

Did loved one commit suicide?Yes
No

If patient did attempt or commit suicide, did patient ever attempt suicide previously?Yes
No

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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