Personal Health BEFORE you began taking PPA
Did you have any significant health issues prior to taking the product(s) containing PPA? Explain:
* Did you have any of the following before you were started taking the product(s) containing PPA?
Yes      No             Yes      No    Irregular heartbeat Kidney disease Abnormal cardiogram Stroke Heart attack Overactive thyroid Heart disease Glaucoma Family history of heart disease Diabetes Hypertension Enlarged prostate High cholesterol Mental illness Congenital heart problem Convulsions/seizures
* Were you taking any medications prior to taking the product(s) containing PPA? [mark appropriate box(es)]
Amantadine (e.g. Symmetrel) Heart Medications Amphetamines Caffeine (e.g. NoDoz) Pemoline (e.g. Cylert) Methylphenidate (e.g. Ritalin) Cocaine Nabilone (e.g. Cesamet) Medication for asthma or other breathing problems Chlophedianol (e.g. Ulone) Monoamine oxidase inhibitors (MAO): Furazolidone (e.g. Furoxone) Selegiline (e.g. Eldepryl) Phenelzine (e.g. Nardil) Tranylcypromine (e.g. Parnate) Procarbazine (e.g. Matulane) Beta-blocking agents: Acebutolol (e.g. Sectral) Oxprenolol (e.g. Corgard) Atenolol (e.g. Tenormin) Penbutolol (e.g. Levatol) Betaxolol (e.g. Kerlone) Pindolol (e.g. Visken) Carteolol (e.g. Cartrol) Propranolol (e.g. Inderol) Labetalol (e.g. Normodyne) Sotalol (e.g. Sotacor) Metoprolol (e.g. Lopressor) Timolol (e.g. Blocadren) Nadolol (e.g. Corgard)
Other medications for colds, sinus problems, hay fever or allergies: (list)
Other appetite suppressants or diet pills: (list)
Other medications: (list)
If you are married, and you were married to the same person when you used the product(s) containing PPA, what is his or her name?
* In what state or states did you live when you were taking the product(s) containing PPA?
* For what purpose were you taking the product(s) containing PPA?
Appetite suppressant Nasal Decongestant Other: (explain)
Brand names of product(s) you used which contained PPA:
Brand 1 Brand 2 Brand 3 Brand 4
* During what period of time did you take the product(s) containing PPA?   Starting Ending
* Were you taking any medications during the time you were taking the product(s) containing PPA? [mark appropriate box(es)]
Amantadine (e.g. Symmetrel) Heart Medications Amphetamines Caffeine (e.g. NoDoz) Pemoline (e.g. Cylert) Methylphenidate (e.g. Ritalin) Cocaine Nabilone (e.g. Cesamet) Medication for asthma or other breathing problems Chlophedianol (e.g. Ulone) Monoamine oxidase inhibitors (MAO): Furazolidone (e.g. Furoxone) Selegiline (e.g. Eldepryl) Phenelzine (e.g. Nardil) Tranylcypromine (e.g. Parnate) Procarbazine (e.g. Matulane) Beta-blocking agents: Acebutolol (e.g. Sectral) Oxprenolol (e.g. Corgard) Atenolol (e.g. Tenormin) Penbutolol (e.g. Levatol) Betaxolol (e.g. Kerlone) Pindolol (e.g. Visken) Carteolol (e.g. Cartrol) Propranolol (e.g. Inderol) Labetalol (e.g. Normodyne) Sotalol (e.g. Sotacor) Metoprolol (e.g. Lopressor) Timolol (e.g. Blocadren) Nadolol (e.g. Corgard)
Other medications for colds, sinus problems, hay fever or allergies: (list)
Other appetite suppressants or diet pills: (list)
Other medications: (list)
Why did you stop using the product(s) containing PPA?
Personal Health AFTER you stopped using the product(s) containing PPA
* Have you experienced any of the following since you first used the product(s) containing PPA?
Yes      No             Yes      No    Irregular heartbeat Kidney disease Abnormal cardiogram Overactive thyroid Heart attack Glaucoma Heart disease Diabetes Hypertension Enlarged prostate High cholesterol Mental illness Stroke Convulsions/seizures
If you believe you have had, or might have had, any kind of bad reaction to PPA, please explain:
If there is something you wish to add, do it here: