BEXTRA BASIC SCREENING QUESTIONNAIRE

Please complete the form below.

Note: fields with a (*) are required.

* Name:

Spouse's Name:

* Address:

* Age:

* Birthdate:

* Phone Number (Home) :

- - X

Phone Number (work):

- - X

Phone Number (cell):

- - X

* E-mail Address:

When did you start taking Bextra:

When did you stop taking Bextra:

Dose Of Bextra:

Please describe any medical problems you had while taking

Have you had severe depression while you were taking Bextra. If so please describe the event.

Has any physician told you that the medical problem you had while taking Bextra was related to Bextra.

List any other medications taken while taking Bextra:

Family history of depression (parent, sibling, aunt, uncle, grandparent; please give best estimate of age of event)

Yes No

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