GEODON 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 Geodon:

When did you stop taking Geodon:

Dose Of Geodon:

Please describe any medical problems you had while taking Geodon:

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

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

List any other medications taken while taking Geodon:

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

Yes No

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