Your CASE

For an efficient evaluation of your case, please make sure you typing correct information. Our specialists will call you back within 24 hours after analyzing information you provided. Thank you!

Name *

First

Last

Phone

Email *

Address

Address Line 1

City

State

Zip Code

Did you receive Reglan®/metoclopramide as tablets, syrup or injection?

Tablets
Syrup
Injection

How long did you take Reglan®/metoclopramide? (check longest period taken)

Only once
A few times
12 Weeks or less
More than a 12 weeks but less than a year
More than a year
2 Years or longer

Have you been diagnosed with (check all that apply):

Tardive Dystonia
Tardive Dyskinesia
Tardive Akathisia
Other Movement Disorder

Who made the diagnosis?

Was the movement disorder attributed to Reglan®/metoclopramide?

Yes
No

When was diagnosis made?

Why were you prescribe Reglan®/metoclopramide? (check all that apply)

Gastroparesis
GERD (gastroesophageal reflux)
Migraine headaches
Other

Have you retained any Reglan®/metoclopramide product, bottles, labels, patient education inserts or other information relating to the Reglan®/metoclopramide that you were prescribed?

Yes
No

Did the healthcare provider that prescribed Reglan®/metoclopramide direct your attention to a black box warning for metoclopramide?

Yes
No

Did your healthcare provider (who prescribed Reglan®/metoclopramide) provide a warning, instructions or other information orally or in writing at any time about the risks of adverse effects increases with long-term use or cumulative dose?

Yes
No
I don't know

Did your pharmacist (who dispensed Reglan®/metoclopramide) provide a warning, instructions or other information orally or in writing at any time about the risk increasing with long-term use or cumulative dose?

Yes
No

Did you receive samples of Reglan® from a health care provider?

Yes
No

Identify the drug stores, mail order pharmacies, internet sites, or other sources from which you purchased or otherwise obtained Reglan®/metoclopramide.

Describe your movement disorder symptoms.

Briefly, tell us about anything else that you think would assist us in addressing your case.

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