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Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
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Zip Code

Please provide the best method and time to contact you:

Date of birth (mm-dd-yyyy):

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

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:

Other Info:

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