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Drug Name (select from list of drugs shown) Emsam (selegiline) Patient Information Patient Phone emsam No . : emsam Prescribing Physician Physician Phone: Physician Address: City, State, Zip: Please circle the appropriate answer for each question .
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emsam ] 5 . Was the patient not responsive to at least two (2) of the following antidepressants with documented trials of clinically sufficient doses and duration of six weeks each or longer: Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), bupropion, emsam mirtazapine, or tricyclic/tetracyclic antidepressants? [If the answer to this question is yes, then skip to question 6 .
Is the patient emsam unable to take any oral preparations including commercially available liquid antidepressants? 6 .

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