SEROQUEL 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 Seroquel:

When did you stop taking Seroquel:

Dose Of Seroquel:

Please describe any medical problems you had while taking Seroquel:

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

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

List any other medications taken while taking Seroquel:

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

Yes No

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