_________________________________________________ Aspartame Consumer Safety Network Questionnaire Please fill in and return to ACSN - PO Box 780634 Dallas TX75378 or EMAIL to ACSN Founder: marystod@airmail.net [and CC -- mgold@holisticmed.com] (Please feel free to attach a letter with more details, preferrably typed. Thank you.) Name_____________________________________________ Age____ Sex: M______F Address___________________________________________ City______________________________________________State____________________ Zip______________________ Tele ( ) Medical problems that you believe are caused from using aspartame: Why do you believe aspartame caused these problems? Did the symptoms go away when you stopped using the products? Did you see a Doctor about symptoms? Did Doctor think it related to aspartame? Did you report your symptoms to the FDA (Food & Drug Admin.) or any other group? What specific products(s) containing aspartame were you consuming when you experienced these symptoms? On the average, what quantity were you consuming (how often, how much each time, etc.) How long had you been consuming these products before you experienced the symptoms? FOR THOSE CONCERNED ABOUT WEIGHT: Did you begin using products with aspartame when you began a restricted calorie diet? 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: Any trouble controlling blood sugar while using aspartame? Did using products affect the types of food you selected to eat? How? Did aspartame affect your desire for sweet tasting food or drink? increase decrease no effect Thank you for taking the time to fill-in and return this questionnaire. In doing so, you are helping others make an informed decision about vital health issues. Mary Stoddard, Founder A.C.S.N.