Did you use Paxil while pregnant?

Contact Information

• First Name:
  Last Name:
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• City:
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• Home Phone:
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• Other Phone:
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Drug used:

• Paxil®
• Generic Sertraline
• Other

Gender of Paxil® user:

• Select One Male Female

Are you (or a loved one) a mother who used Paxil® while pregnant?

• Select One Yes No

Was your child born with any of these conditions?

• Heart Murmur
• Heart Defects
• Lung Disease / Pulmonary Hypertension
• Craniosynotosis / Misshapen head / Facial deformity
• Limb Defect / Genital Defect
• Extreme Behavioral Disorder
• Attempted Suicide
• Breathing Problems / Asthma
• Miscarriage
• Fetal Death
• Atrial Septal Defect (ASD)
• Tetralogy of the Fallot
• Transposition of the Great Arteries
• Ventrical Outflow Defect
• A Ventrical Septal Defect (VSD)
• Hypoplastic Left Heart Syndrome (HLHS)
• Hypoplastic Right Heart Syndrome(HRHS)
• Hole in Heart
• Cleft lip/Cleft Palate
• Club Foot
• Pulmonary Hypertension in newborn(PPHN)
• Pulmonary Stenosis
• Anal Atresia
• Abdominal Defects/Omphalocele
• Other / ADHD / Learning disability

Date of Birth of Injured Child :

• Select One No Injured Child Miscarriage 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 or Before

Name of Child:

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