Anti-Anxiety Medication Survey

If you have taken an anti-anxiety medication, sleep medication, anti-psychotic, or any other miscellaneous medications to treat your reaction, please take a moment and fill out this survey. Although it looks long, it should only take a few moments. Results will be used to help shed light on a ongoing controversy in the evolution of FQ reactions. Thank You.

Name of FQ you took?:

Reaction Month and Year?:

What type of Reaction do you believe that you had, or are having?
MildIntermediateSevere - AcuteSevere - Delayed

What Type of anti-anxiety/sleep medication did you take?:

A. Did you take a Benzodiazapine?
NoYes. What type and how long?

B. Did you take a SSRI?
NoYes. What type and how long?

C. Did you take a Sleep Medication?
NoYes. What type and how long?

D. Did you take some other kind of anti-anxiety medication?
NoYes. What type and how long?

Do you believe that taking this medication hampered your recovery?
NoYes. Please Explain

Your Email (optional, Always Kept Confidential):

Your First Name (optional):

Age? (Optional):

Sex (Optional):

May I contact you at the above email address if I have any further questions regarding your information that may help others?
YesNo

Would you be interested in participating in any future FQ research should it become available?
YesNo

Please type the letters in the box as you see them.
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