ZYPREXA 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 Zyprexa:

When did you stop taking Zyprexa:

Dose Of Zyprexa:

Please describe any medical problems you had while taking Zyprexa:

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

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

List any other medications taken while taking Zyprexa

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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