* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date you started taking this drug:

Date you stopped taking this drug:

What condition was this medication prescribed to treat?

Name(s) of all antidepressants taken:

Age of patient when antidepressant(s) prescribed:

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

Please describe hospitalization or institutionalization:

Age of patient when incident occurred:

Please further describe side effects:

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