RISPERDAL 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 Risperdal :

When did you stop taking Risperdal:

Dose Of Risperdal:

Please describe any medical problems you had while taking Risperdal:

Have you been diagnosed with diabetes, Tardive, Dyslexia, Pancreatitis while you were taking Risperdal. If so please describe the event.

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

List any other medications taken while taking Risperdal:

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

Yes No

Client history of diabetes (please note if diabetes medication and/or diet treatment)

Yes No

Client smoking history

Yes No

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