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* First Name

* Last Name

* Email

* Phone

Cell Phone

Date you started taking this drug:

Date you stopped taking this drug:

Was suicide attempted?
Yes
No

Did loved one commit suicide?
Yes
No

What condition was this medication prescribed to treat?

What additional medications were you taking at the time?

If patient did commit suicide, what was the method of suicide?

If patient did attempt or commit suicide, did patient ever attempt suicide previously?
Yes
No

Please describe any psychiatric conditions diagnosed before starting Neurontin:

Did Neurontin help the condition that it was prescribed for?
Yes
No, my condition stayed the same
No, my condition worsened

Please further describe side effects:

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