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ADD Conspiracy Research PDF Print E-mail
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ADHD - Printable Forms
Friday, 02 January 2009 12:45


                       Conspiracy Research


Print your name (in English) _________________________________________________

Address ____________________________________________________

City __________________________ State _____________ Zip __________________

E-Mail address; Phone __________________

Name of person affected _______________________________ Age today ________

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

selection ADD,selection ADHD,selection ODD,selection OI,selection SA,selection Depressed, or selection Other ________________________________
Medication(s) prescribed:
selection Ritalin,selection Prozac,selection Paxil,selection Cylert, selection Adderal or selection Other ________________________

Medication taken how long? From age _______ to age _______.

Was it ever given at school? selection Yes, selection No

Did a school teacher or school employee first suggest
that your child should be "tested" or medicated?
     selection Yes, selection 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? selection Yes, selection No
If Yes, please describe your experience: _________________________________________________


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

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


We welcome any additional comments, ideas, or questions you may have. Please attach them on a separate sheet(s) of paper and send them along with this form to:
c/o Allan B. Colombo
P.O. Box 30076
East Canton, Ohio 44730