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Please complete our Ability Questionnaire to see if you may have a case.
Date of Birth
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
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?YesNo
Did you have to go to a hospital for treatment? YesNo
If so how many days?
What treatment did the hospital provide?
Any previous history of addictive behavior?YesNo
If yes, please explain
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?