Did you take PAXIL during your pregnancy?

Paxil, a drug in the class of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs), has been linked to birth defects -- in particular, heart defects. SSRIs are prescribed for the treatment of depression and anxiety disorders. Manufactured by Glaxo-Smith Kline, Paxil (paroxetine) was released in 1992 and has become one of the most widely sold antidepressants ever.

Paxil Questionnaire

Fill out this questionnaire or download a copy of the questionnaire. Or, click here to fill out a shorter form.

Contact Info: (The person who contacts us requesting information)

Last Name:
First Name:
MI:

Home Phone:
Work Phone:
Email:

Street Address:
City:
County:
State:
Zip:

Client Info: (The potential plaintiff)

Last Name:
First Name:
MI:

Home Phone:
Work Phone:
Email:

Street Address:
City:
County:
State:
Zip:

Social Security #:
Date of Birth:
Date of Death:

Was an autopsy performed?
Yes: No:

In what County and state was the autopsy performed?

Emergency Contact Information:

Litigation against pharmaceutical companies frequently lasts several years. Our experience is that people move during that time and often forget to notify us of their new contact information. Please remember to notify us if you move and change your contact information. Please also provide us with contact information of someone who will always know how to reach you.

Last Name:
First Name:
MI:

Male/Female
Male: Female:

Home Phone:
Work Phone:
Email:

Street Address:
City:
County:
State:
Zip:

Paxil Exposure:

Who prescribed Paxil for you?

Doctor

Prescribing doctor:
Address:
City:

Dosage

Dosage given:
Dosage taken:
Date taken:
Date stopped:
Total time taken:

Pharmacy

Pharmacy Name:
Street Address:
City:
State:
Zip:
Phone:

Prescription Details

Why was Paxil prescribed for you?

What did the doctor who prescribed Paxil for you tell you he was prescribing it for?

Were you pregnant when the doctor prescribed Paxil for you?
Yes No

Did you become pregnant while you were prescribed Paxil?
Yes No

When the doctor prescribed PAXIL for you, did you tell the doctor that:
you were pregnant? you were thinking about getting pregnant?

When you learned that you were pregnant, did you tell the doctor that you were pregnant? Yes No

If yes, how soon after you learned you were pregnant did you tell the doctor?

Did the doctor who prescribed Paxil for you tell you that you cannot take Paxil if you are pregnant? Yes No

Did the doctor who prescribed Paxil for you tell you that Paxil can cause heart defects in unborn? Yes No

Did the doctor who prescribed Paxil for you tell you that Paxil can cause a deadly lung disease called PERSISTENT PULMONARY HYPERTENSION (PPHN) in newborn babies? Yes No

Did the doctor who prescribed Paxil for you discuss the risks and benefits of taking Paxil while you were pregnant? Yes No

After taking Paxil during your pregnancy, was your child born with cardiac defects? Yes No

After taking Paxil during your pregnancy, was your child born with an atrial or ventricular septal defect (Conditions in which the wall between the right and left sides of the heart is not completely developed.) ? Yes No

After taking Paxil during your pregnancy, was your child born with and/or diagnosed with PERSISTENT PULMONARY HYPERTENSION (PPHN)? Yes No

Diagnosing doctor:
Address:
City:
Diagnosis date:

Treatment given to your child for cardiac defects?

Treatment given to your child forPERSISTENT PULMONARY HYPERTENSION (PPHN)

Doctor's Name:
Address:
City:
Zip:
Phone:

Hospital Name:
Address:
City:
Zip:
Phone:

Medical History:

Your Medical History Prior To Taking Paxil:

Were you born with a heart defect?
Yes No

Hospital Name:
Address:
City:

Doctor's Name:
Address:
City:

Had you been diagnosed by a doctor or at a hospital for PERSISTENT PULMONARY HYPERTENSION (PPHN)? Yes No

Hospital Name:
Address:
City:

Doctor's Name:
Address:
City:

Family Medical History

Do you have a family history of heart defects?
Yes No
Who (parent, sibling, child, etc.)?

Do you have a family history of PERSISTENT PULMONARY HYPERTENSION (PPHN)?
Yes No
Who (parent, sibling, child, etc.)?

Do you have a family history of Pulmonary Hypertension or Primary Pulmonary Hypertension?
Yes No
Who (parent, sibling, child, etc.)?

Final Comments

What Paxil treatment did you recieve?
Are you still under a doctor's care? Yes No

How is your life different today as a result of your child's Paxil-related problems?

Comments and/or questions:

Submit Questionnaire

Did you take PAXIL during pregnancy? - If so, and your child was born with a birth defect, then please contact Bailey & Galyen immediately about filing your claim. 800.529.8008

Houston Clear Lake/Nasa
18333 Egret Bay Blvd, Suite 120
Houston, TX 77058
281.335-7744

Dallas
4131 N. Central Expressway
Suite 860
Dallas, Texas 75204
800-529-8008

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