* In what state or states did you live when you were taking Ephedra?
* Brand(s) of Ephedra you used:
	Brand 1:
	Brand 2:
	Brand 3:
	Brand 4:
* Was Ephedra used by you for the following:
Yes      No    Weight Loss Improve Athletic Performance Muscle Building Other (specify below):
* Did you have any of the following before you started taking Ephedra?
Yes      No             Yes      No    Irregular heartbeat Low calcium Abnormal cardiogram Low potassium Heart disease Low magnesium Lung disease Persistent vomiting Kidney disease Acute dehydration Bulimia or anorexia Family history of heart disease Hypertension Congenital heart problem Diabetes Rheumatic fever High cholesterol Mitral valve prolapse Cardiac catheterization Cardiac artery bypass surgery Echocardiogram Cardiac artery angioplasty Thyroid Problem Breast Feeding
* During what period of time did you take Ephedra?   Starting Ending
*  Were you given an electrocardiogram (EKG or ECG) before you started taking Ephedra? Yes      No
What were the results?
*  Were your electrolytes checked before you were started on Ephedra? Yes      No
*  How many milligrams of Ephedra were contained in each of the Ephedra products you used? Brand 1: Brand 2: Brand 3: Brand 4:
If you are married, and you were married to the same person when you took Ephedra, what is his or her name?
* Did you take any of the following during the time you were taking Ephedra?
Yes      No           Blood Pressure Medication Sudafed Fen Phen Caffeine Mao Inhibitor Nardil Parnate Anti Microbials (i.e., Furazolldone)
* Have you experienced any of the following since you first took Ephedra?
Yes      No             Yes      No    Ventricular tachycardia Cardiac arrest Ventricular fibrillation Heart attack Torsades de pointes Difficulty breathing QT prolongation Shortness of breath Unusual weakness Dizziness Unexplained vomiting Fast heartbeat Stroke Irregular heartbeat Seizure Electrolyte imbalance Intracranial Bleed
* Why did you stop taking Ephedra?
If you believe you have had, or might have had, any kind of bad reaction to Ephedra, please explain:
If you have had any kind of significant health problems, please explain them here:
If there is something you wish to add, do it here: