May 12, 2008
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Lariam Intake

Please fill out the form below to have your case evaluated. Provide as much information as possible to speed the processing of your inquiry.

Full Name


Email Address


Home Phone


Other Phone


Address (City, State, Zip)


What is the best way to reach you? Please provide the best place, time and method for contacting you.


Injured Person Date of Birth


During what period of time was Lariam taken? Start - End


List names/addresses of any doctors who prescribed Lariam


Why was Lariam perscribed?


Were any other medications taken with Lariam? If yes. list other medications taken


Did Lariam appear to cause depression?
Yes
No

Did Lariam appear to cause other psychological effects?
Yes
No

Was suicide attempted?
Yes
No

Did loved one committ suicide?
Yes
No

Was depression a problem before taking Lariam?
Yes
No

Was a Psychiatrist/Psychologist ever seen before taking Lariam?
Yes
No

If yes please describe treatment


Please describe other medical problems associated with Lariam use




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