PPA Phenylpropanolamine Claim History Questionnaire for a Deceased Person

This questionnaire is intended to provide the basic information necessary to evaluate your claim for compensation arising from a child's use of a product or products containing PPA (Phenylpropanolamine). Please complete it to the best of your ability with as much detail as possible. Any information you submit will be kept strictly confidential.

Please complete the form and click the "submit" button at the end to send the information to us electronically. Note that information in fields marked with an asterisk must be completed in order for this form to be processed.

You may also complete the form, print out and mail to:
Joseph Santoli • 615 Franklin Turnpike • Ridgewood NJ 07450-1929
or fax toll-free to: 1-877-926-9210

PPA (Phenylpropanolamine) Claim History Questionnaire for a Deceased Person

* Decedent's Name:
* Decedent's Age at Time of Death:
* Date of Decedent's Death:
* Decedent's Birthdate:
* Decedent's Social Security Number:
* Cause of Death as Shown on Death Certificate:
* Your Name:
* Your Relationship to Decedent:
* Your Telephone Number:
* Your Mailing Address:


* Your E-mail Address:

Health of Decedent BEFORE he or she began taking PPA

Did the decedent have any significant health issues prior to taking the product(s) containing PPA? Explain:

* Did the decedent have any of the following before he or she started taking the product(s) containing PPA?

  Yes      No             Yes      No

Irregular heartbeat Kidney disease

Abnormal cardiogram Stroke

Congenital heart problem Overactive thyroid

Heart disease Glaucoma

Heart disease Diabetes

Convulsions/seizures Enlarged prostate

Mental illness

* Was the decedent 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)

* In what state or states did the decedent live when he or she was taking the product(s) containing PPA?

* For what purpose was the child taking the product(s) containing PPA?

Appetite suppressant Nasal Decongestant

Other: (explain)

Brand names of product(s) the decedent used which contained PPA:

Brand 1

Brand 2

Brand 3

Brand 4

* During what period of time did the decedent take the product(s) containing PPA?   Starting Ending

* Was the decedent taking any medications during the time he or she was 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 the decedent stop using the product(s) containing PPA?

Personal Health AFTER decedent stopped using the product(s) containing PPA

* Did the decedent experience any of the following after he or she 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 the decedent 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:

©2000 Joseph R. Santoli, Esq.
615 Franklin Turnpike
Ridgewood NJ 07450-1929
Toll-Free (877) 926-9202 • Phone (201) 444-2888 • Toll-Free Fax (877) 926-9210