Questionnaire about Psych Drug Effects & Withdrawal
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1. Which psych drug(s) have you used, stopped or withdrawn from?
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2. Before you stopped taking the drug, which effects did you have? (Such as increased nervousness, insomnia, weight gain, sedation, anorgasmia, and the like?)
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3. On a scale of 1 to 10, with 10 being the most helpful and 0 being of no help, and minus 10 as your feeling much worse, how helpful or unhelpful was each drug for you?
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4. How long did you take each drug?
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5. Did the original prescribing physician or psychiatrist warn you in a clear way about toxic effects, including that of drug withdrawal difficulty? Please explain any details.
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6. Which symptoms did you notice when you were withdrawing from each drug?
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7. What method did you use to withdraw (such as, e.g., stopping suddenly, very gradual withdrawal over time, or the like)?
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8. Did you ever feel suicidal or extremely angry or rageful while either taking a drug or withdrawing from it? (And these feelings were not present before you took the drug). If so, please explain details.
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9. Did any psychiatrist tell you that any of these were your "original symptoms" returning instead of saying they were withdrawal symptoms? Did they prescribe any other psych drugs at that time?
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Thank you for filling out this survey.

This survey serves two purposes:

1) It will provide me some useful clinical information to assist you in your healing process.

2) It may provide the possibility of compiling your information with that of others for use in a published article. Your name and any other identifying features regarding any information that you provide will be kept strictly confidential.

I have read the above, I understand it and agree to having this information published anonymously.
Signed ________________________________________ Date ___________________
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Once completed, please Fax to: 404-843-4300
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Copyright© 2004, 2009 Charles L. Whitfield, MD Fax: 404-843-4300 eMail: c-bwhit@mindspring.com

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