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Paxil
Name:
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Evening Phone:
Best time to call:
Please provide the following information to allow us to better serve you:
1. Approximate dates of Paxil use From:
To:
2. What dosage did you take per day?:
3. Are you currently pregnant?:
4. Has your fetus been determined to have congenital malformations or birth defects?:
Yes
No
5. Do you have a child with malformations or birth defects?:
Yes
No
6. If so, when was your child born? :
7. Please describe the malformation or birth defect:
8. Did you take Paxil in your first 3 months of pregnancy?:
Yes
No
Other condition: (Please explain):
6. Did your physician tell you that any problems with your pregnancy or with your child may be related to Paxil?:
Yes
No
If you have any questions regarding Paxil, please contact Lynn Seithel at 843 216 9134.
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