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Monday, May 4, 2015

ADVERSE REACTION QUESTIONNAIRE (Please Fill In & Return For Our Files)



Aspartame Consumer Safety Network & Pilot Hotline Questionnaire
EMAIL to ACSN Founder: marystod@airmail.net 
(FACT SHEET available by email) 
_____________________________________________________                                                                          
Name: (First)                            (MI)              (Last)
Street:
City:
State/Zip:
Country:
Phone:                          (res.):                     (cell):                           
Email address:
Age:        Sex: 
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(Reported symptoms of Aspartame poisoning include:
migraines, gastrointestinal, vertigo, insomnia, numbness of extremeties, blurred vision, blindness, hemorrhaging and other eye problems, memory loss, confusion, slurred speech, mild to suicidal depression, personality disorders, hyperactivity in adults and children, nausea, seizures including grand mal, skin lesions, bladder problems, rashes, anxiety/phobia attacks, muscle cramping, twitching and joint pain, mood swings, fatigue, PMS, menstrual disfunction, impotency, heart attack symptoms, hearing loss and tinnitus, loss or change of taste, edemas and death.)
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Q.  Name medical problems YOU experienced while using aspartame (™ NutraSweet; Equal; Neotame; Advantame; AminoSweet; TwinSweet; Canderel, etc.)
A.

Q.  Have you been diagnosed with any form of malignancy that coincided with your aspartame use? (Aspartame caused brain, uterine, pancreatic, liver, kidney, lung and mammary tumors in lab animals when tested.) Latest studies include: lymphoma and leukemia as well.
A.

Q.  Did your symptoms go away or diminish when you stopped using the sweetener?
A.

Q.  How long have you been Aspartame-free?
A.

Q.  Did you see a Doctor about any of these symptoms?
A.

Q.  Did your Doctor think it could be related to aspartame? 
A.

Q.  Did your Doctor advise you to stop using aspartame? 
A.

Q.  Did you use aspartame while pregnant? (Give approx. amounts.)
(Aspartame changes DNA and has caused birth defects in lab animals.)
A.

Q.  Did you report your symptoms to the FDA (Food & Drug Admin.) or any other group?
A.

Q.  Name the specific products(s) containing aspartame you were consuming when you experienced these symptoms. (Brand names.)
A.

Q.  On the average, what quantity were you consuming (how often, how much each time, etc.) 
A.

Q.  Did you ever feel addicted to your sweetener? (Describe)
A.

Q.  How long had you been consuming aspartame before you began to experience any symptoms?
A.

FOR THOSE CONCERNED ABOUT WEIGHT: 
Did you begin using products with aspartame when you began a restricted calorie diet or joined a weight loss program?

Did you use aspartame products only for some of your meals to save calories?

Did aspartame seem to help you lose weight at first?

What were the long term weight loss effects of using aspartame.

FOR THOSE WITH DIABETES:

Q.  Did your Doctor or a Registered Dietitian tell you to use aspartame?
A.                        

Q.  Any trouble controlling blood sugar levels while using aspartame? (Explain)
A.

Q.  Did using aspartame affect the types of food you selected to eat?
A.
Q.  How?
A.

Q.  Did you contact the American Diabetic Association, Registered Dietitians or any other group about your problems w/Aspartame? If yes, what was their response?
A.

Q.  Did Aspartame affect your desire for sweet tasting food or drink? 
A.
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Remember, Aspartame is often the unidentified environmental trigger for: Epstein Barre - Chronic Fatigue Syn. - Post Polio Syn. - Lyme Disease - PMS - Carpal Tunnel - Arthritis - Meniere's - Alzheimer's - ALS (Lou Gehrig's Disease) - MS - Epilepsy - Anxiety/Phobia Disorders - PMS - PTSD - PAD - SAD - EMS - Graves - False Memory - Brain tumors - Fibromyalgia - Stroke - Heart Disease - Attention Deficit Disorder - Birth Defects - Miscarriage - other Rare or "Difficult-to-Diagnose" Diseases.
_____________________________________________________

Thank you for taking the time to fill out and return this form. If you wish, you may attach a narrative re: Your Story, and/or any Pathology Lab Reports you may have in the way of documentation.Your cooperation and assistance may help save a life! May we have permission to  publish your data to help others?  
Mary Nash Stoddard, Founder A.C.S.N. and Worldwide Pilot Hotline.


Mary Nash Stoddard