Full Name:  * Address [Optional] City & State:  * Email Address:  * Best Phone #  * Cell or Work Phone: [Optional]  * Name of Reglan User  * Current age of Reglan user  * Which medications did you take: Reglan tablets Metoclopramide (Generic) Oral Disintergrating pills Metoclopramide oral solution Reglan injections How many total months or years was Reglan taken:  * What side effects below do you currently have or noticed: Twitching Abnormal Head Movements Involuntary Facial Movements Tongue & Lip Smacking Lip Puckering Rapid Eye Movements Eye Blinking Frowns & Grimacing Expressions Shaking of Hands Shaking of Feet Eye Blinking Other injuries When did these symptoms first start:  * Have you been diagnosed with Tardive Dyskinesia (TD) or ?:  * Date and City & State of TD Diagnosis: Check Those that you have taken in the past: Abilify Clozaril Etrafan Geodon Haldol Loxitane Mellaril Moban Navane Orap Permitil Phenegan Risperdal Serentil Seroquel Stelazine Thorazine Triavil Zyprexa NONE OTHER Please discuss in detail any other important facts or comments that you have:  * Do not enter anything in this field:

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