Areas of Expertise:
Paxil Withdrawal

If you are interested in us evaluating your condition, please click here to fill out a questionnaire. The information you provide will enable us to determine the viability of any potential claim you may have.

Today's Date:
Name:
Address:
City/State/Zip:
Email Address:
Home Phone:
Place of Employment:
Occupation:
Work Phone:
Social Security #:
Date of Birth:
Name of Spouse:

Children (names and ages):


Time period during which Paxil was taken:
Start Date:
End Date:

Doctor(s) who prescribed Paxil and dates of treatments. Include doctor's address:


Where did you purchase the Paxil prescribed to you (Name and Address of pharmacy):


Please check below each symptom you experienced, whether each symptom was a Side Effect Symptom (a symptom that occurred while taking Paxil) or Withdrawal Symptom (a symptom that occurred only while reducing or stopping Paxil):
SymptomSide Effect SymptomWithdrawal Symptom
Aggression
Agitation
Confusion
Diarrhea
Dizziness and/or light headedness
Extreme nausea and/or vomiting
Fatigue
Flu symptoms
(abdominal discomfort, weakness, etc.)
Jolting electric "zaps"
Lethargy
Memory and concentration difficulties
Nightmares and/or sleep disturbance
Suicidal ideation(s) [thoughts]
Suicide attempt(s)
Sweating
Tremor
Vertigo
Other

Were you (the Paxil user) hospitalized as a result of these reactions?
Yes No
If so, what hospital(s) and what date(s)?

Did you discuss these adverse effects with your doctor?
Yes No
If so, what was his/her explanation of why you were experiencing withdrawal symptoms?



List any other medications you were taking at the time you experienced the withdrawal symptoms listed above (please list the name of the drug and the dose you were taking):


Original reason for taking Paxil (Please indicate the initial diagnosis that was made by your doctor.):


Before or at any time you were prescribed Paxil, did you receive any information about the addictive properties of Paxil or the potential for Paxil to cause withdrawal?
Yes No

If so, please indicate the contents and source of the information


WE WOULD LIKE TO KNOW HOW YOU WERE INTRODUCED TO PAXIL
Was Paxil suggested by a doctor or medical facility?
Yes No
Were you persuaded to seek additional information or a prescription for Paxil by:
TV Commercials?
Yes No
Radio Commercials?
Yes No
Print Ads?
Yes No
Were you given free Paxil samples?
Yes No
Did you report any of the problems you were experiencing to GlaxoSmithKline, the pharmaceutical manufacturer of Paxil?
Yes No
If so, please indicate the response you received from GlaxoSmithKline:

Did you report any of the problems you were experiencing to the Food and Drug Administration (FDA)?
Yes No
If so, please indicate the response you received from the FDA:

Have you ever been addicted to any drug or substance in the past (including alcohol or cigarettes)?
Yes No
If so, please indicate the substance and the length of the addiction

Have you ever been treated by a psychiatrist, psychologist, psychiatric nurse practitioner, or social worker in the past?
Yes No
If so, please indicate their name(s) and address(es) and the time period when you were treated by them.

Have you ever been diagnosed with depression, social anxiety, obsessive compulsive disorder, or any other related diagnosis prior to the initial diagnosis listed above?
Yes No
If so, please list the diagnosis, the time of such diagnosis, the treatment prescribed for that diagnosis, and the length of time that treatment was used:

Please list any other medical history (briefly):

 

Milwaukee, WI 53202
Phone: (414) 271-1011

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