PAXIL CASE FORM

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Title:
First Name: *
Last Name: *
E-mail Address:
Address:
 
City:
State:
Zipcode:
Phone: () - ext.

Paxil Questions

Date Started Taking Paxil
Date Ended Taking Paxil
Dosage
State where Paxil prescribed

Birth Defect Questions

Did you use Paxil during pregnancy? Yes No
Date of birth of child (if birth defect case)
Did your child have any birth defects? Yes No
If yes, please describe:

Suicide Questions

Date of Suicide/attempt (if suicide case)
Was there an attempted suicide while on Paxil? Yes No

Other Questions

Were there any other injuries caused by Paxil? Yes No
Additional Comments: