Full Name:  * Address: [Optional] City & State:  * Phone Number (Best #)  * Phone Number (Cell #) [Optional] E-mail Address:  *   Name of Reglan User  * Current age of Reglan user  * How many total months or years was Reglan used:  * When did these symptoms first start:  * What injuries or symptoms have you 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 Have you been diagnosed with Tardive Dyskinesia or Dystonia or ?:  * Date of Diagnosis: Anti-Psychotics Taken in Past: Abilify Clozaril Etrafan Geodon Haldol Loxitane Mellaril Moban Navane Orap Permitil Phenegan Risperdal Serentil Seroquel Stelazine Thorazine Triavil Zyprexa NONE Other Anti-Psychotics: Please describe in detail the facts surrounding your condition or any questions you may have: Do not enter anything in this field:

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