Name

Phone Number

E-mail Address

Drug You Were Taking:

Select One Avandia® Ambien® Chantix® Fosamax® Kugel® Hernia Patch Mirapex® Gadolinium MRI Contrast Dye Ortho Evra® Permax® SSRIs Strattera® Tequin® Zelnorm® Zicam®

When did you begin taking the drug?

When did you stop taking the drug?

What dosage of the drug were you taking?

What side effects to you suffer?

Additional Details