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Abilify Free Case Evaluation Questionnaire

Abbott Law Group, P.A. > Abilify Lawsuit > Abilify Free Case Evaluation Questionnaire

Please complete our Ability Questionnaire to see if you may have a case.

Contact Information

Name:

Phone

Email

Date of Birth

Mailing Address

Prescription Information

Date started taking abilify

Still Taking Abilify or Date you stopped?

Name and Adress of Pharmacy

What was the dosage(Was it increased)?

Name and Address of Doctor who prescribed Abilify

Reason for taking Abilify

Diagnosis and Treatment

Have you developed an uncontrollable compulsive behavior?

No, I have notCompulsive GamblingBinge EatingImpulse SpendingSexual AddictionOther

If yes, please explain and has the behavior been diagnosed by a doctor?

Name and Address of Doctor

Are you seeking treatment for the behavior?

Did you have to go to a hospital for treatment?

If so how many days?

What treatment did the hospital provide?

Any previous history of addictive behavior?

If yes, please explain

Important Dates and Other Information

Please list all States where treatment occurred and prescriptions were filled.

Do you have the medication bottle or any unused medication?

Do you have your pharmacy records and medical records?

When did you find out about the possible connection between Abilify and the compulsive behavior?

Do you have any history of arrests?

Please list any additional information you would like us to know about.

How did you find us?