* First Name
* Last Name
-U.S. Virgin Islands-
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?YesNo
Did patient become violent during or after taking the drug?YesNo
Was suicide attempted?YesNo
Was hospitalization or institutionalization required after taking antidepressant(s)?YesNo
Did loved one commit suicide?YesNo
If patient did attempt or commit suicide, did patient ever attempt suicide previously?YesNo
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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