Conspiracy Research

Print your name (in English) _________________________________________________

Address ____________________________________________________

City __________________________ State _____________ Zip __________________

E-Mail address _________________@____________.com; Phone __________________

Name of person affected _______________________________ Age today ________

Which of the following was he/she diagnosed, labeled, or suspected to be:

ADD, ADHD, ODD, OI, SA, Depressed, or Other ________________________________

Ritalin, Prozac, Paxil, Cylert, Adderal or Other ________________________

Was it ever given at school? Yes, No

Did a school teacher or school employee first suggest that your child should be "tested" or medicated?

Yes, No

Name of School _______________________ School District _______________________

Name of the Physician who prescribed the above medication(s) _________________________

Address or location: ______________________________________________________

Please look at the list of 47 reported side effects (this will open a new window in your browser).
If the affected person suffered from or was observed to have any of them, please list (by number) the five (5) most important or predominant ones: ( _____ ), ( _____ ), ( _____ ), ( _____ ), ( _____)

Have you ever had direct dealings or involvement with CHADD? Yes, No
If Yes, please describe your experience: _________________________________________________

_______________________________________________________________________________

Would you be interested in participating in a class-action lawsuit? Yes, No

Please list anyone you feel should be listed as defendants in addition to: Novartis, CHADD,
and the A.P.A. (American Psychiatric Association): _______________________________________

_______________________________________________________________________________