---------- Forwarded message ---------- Date: Tue, 5 Sep 1995 21:24:43 -0400 From: ElaineHF@aol.com To: bettym19@mindspring.com Cc: ElaineHF@aol.com Subject: Dr. Roberts Survey/ck format PALM BEACH INSTITUTE FOR MEDICAL RESEARCH, INC. 6708 Pamela Lane West Palm Beach, FL 33405 FAX 561-547-8008 H. J. Roberts, M.D. Medical Director VOLUNTARY QUESTIONNAIRE FOR PERSONS WITH POSSIBLE REACTIONS TO PRODUCTS CONTAINING ASPARTAME (NutraSweet, Equal, Crystal Light, etc.) #___________ I. GENERAL INFORMATION NAME (Omit if you Wish) ________________________________________________________________ ADDRESS (Omit if you Wish) _____________________________________________________________ ______________________________________________________________________________ TELEPHONE NUMBER (Omit if you Wish) Area Code _______ # _______________________________ SEX Male ____________ Female ______________ RACE White ____________ Black _______________ Other _________ PRESENT AGE (years) ______________ OCCUPATION _________________________________________________________________________ II. INFORMATION ABOUT YOUR PRIOR USE OF ASPARTAME Age when your first reaction occurred ___________________________ years How long had you been eating or drinking aspartame before then? (Note: Aspartame was first put in soft drinks in July 1983) _______ Days _________ Weeks _________Months _________ Years ______________________________________________________________________________ ______________________________________________________________________________ (Do NOT Enter) Computer Code HR AV WM MR CNI FDA CDC _____ _____ _____ ______________________________________________________________________________ ______________________________________________________________________________ Did you GREATLY increase such use BEFORE these symptoms occurred? Yes ______ No_______ (If “Yes,” how long BEFORE your symptoms occurred?) ______Days _______Weeks ________Months _________Years Why did you use or increase products sweetened with aspartame? I preferred their taste__________ Great thirst in hot weather____________ I wanted to avoid sugar because of: Diabetes __________ Hypoglycemia (low blood sugar) ____________ An overweight problem _____________ A skin Condition________________ Other ______________________ Did you use aspartame-sweetened products under these conditions? While PREGNANT for __________weeks _________ months While BREAST-FEEDING for __________weeks __________ months How much do you estimate that you were eating or drinking aspartame-sweetened products DAILY when your symptoms began? Some examples: Diet Coke, Diet Pepsi, Crystal Light, Fresca, Diet RC Cola, various-brand cocoa or chocolate mixes, D-Zerta, or Jell-O gelatins or puddings, various-brand pre-sweetened cereals, iced tea mixes, powdered soft drinks. ______ cans (12 ounces) of (name of product) _______________________________ ______ small bottles (6 ounces) of (name) __________________________________ ______ large bottles (liter or 33 ounces) of (name)____________________________ ______very large bottles (2 liters or 67 ounces) of______________________________ ______packets of table-top sweetener (name)__________________________________ ______regular glasses of iced tea (name)______________________________________ ______regular glasses of Kool-Aid type mix (name)______________________________ ______regular glasses of hot chocolate (name)__________________________________ ______bowls of cereal (name)_______________________________________________ ______servings of puddings or gelatins (name)__________________________________ ______sticks of gum (name)________________________________________________ ______(envelopes) or (teaspoons) of other products (name)_______________________ Were you on a STRICT diet to lose weight when your problem began? Yes_____ No _____ If “Yes,” for how long? ________weeks ______months Were you REALLY exercising to lose weight when your problems began? Yes_____ No_____ III. SUSPICIONS ABOUT ASPARTAME CAUSING OR AGGRAVATING YOUR CONDITIONS Who or what FIRST made you think that aspartame might be causing your symptoms ? Myself___________ A relative_____________ A friend_____________ My own doctor___________ A Nurse___________ A newspaper article__________ A TV program______________ A medical specialist (name)___________ Other (please state)_______________ Did you then COMPLETELY stop using aspartame? Yes______ No______ If you stopped, DID YOUR SYMPTOMS IMPROVE? Yes______ No______ How soon did your symptoms BEGIN to improve AFTER you stopped? ______Days ______Weeks ______Months Did ALL of your symptoms DISAPPEAR after you stopped? Yes______ No______ If “Yes,” how soon? ______Days ______Weeks ______Months If you felt better, what problems STILL persisted? _____________________________________________ ______________________________________________________________________________ If you felt better, did you symptoms RETURN when you ate or drank these products AGAIN? Yes______ No______ If “yes,”, HOW SOON did the symptoms come back? ______Days ______Weeks ______Months How many times did you then RETEST yourself before you became CONVINCED that aspartame product(s) REALLY caused your symptoms? ___1 ____2 ____3 ____4 Did the symptoms return after you ate or drank something YOU DIDN’T KNOW contained aspartame? ______Yes ______No If “yes,”, what was the product? ________________________________________ Did your symptoms SIGNIFICANTLY affect your business or personal life? Yes______ No______ If “yes,”, how or how much? A bit________ Severely (loss of job, stopped school, divorce, etc.)_______________ I was incapacitated______________ I lost my driver’s license____________ I lost my pilot’s license_____________ Describe fully______________________________________________________________________ ______________________________________________________________________________ IV. REACTIONS I ATTRIBUTE TO ASPARTAME Please check or circle ANY of the following complaints that you or your doctors thought might be caused by, or aggravated by, aspartame. (Elaborate later if you wish). EYES: A marked decrease of vision in _____One Eye ______Both Eyes Loss of vision in _____ One Eye ______Both Eyes Pain in _____ One Eye ______Both Eyes Recent “dry eyes” _____ Yes ______ No Recent trouble wearing contact lens _____ Yes ______ No EARS Ringing or “cracking” in _____One Ear ______Both Ears Loss of hearing in _____One Ear ______Both Ears Severe sensitivity to noise in _____One Ear ______Both Ears BRAIN AND HEAD ______Severe headaches ______Severe dizziness or feeling lightheaded ______Severe unsteadiness of my legs ______Convulsions (seizures, epilepsy) How many attacks? _____1 _____2 _____3 _____4 _____More Was your brain wave test (EEG) abnormal? ______Yes ______No _____ Epilepsy-like “fits” WITHOUT convulsions (also known as petit mal, psychomotor attacks) _____Severe drowsiness and falling asleep (without reason) _____Severe shaking (tremors) _____Severe insomnia (trouble sleeping) _____Severe mental confusion _____Marked memory loss _____Severe hyperactivity (as jumping of the arms or “restless” legs) _____Unexplained pains in or around your face _____Slurring of your speech _____Severe depression Did you actually think about suicide? _____Yes _____No _____Extreme irritability _____Severe “anxiety attacks” _____Marked “personality changes” _____Severe aggravation of phobias (such as fear of crowds or heights) CHEST _____Attacks or shortness of breath _____Palpitations (heart fluttering) _____Rapid heart beat attacks _____Unexplained chest pains _____Recent high blood pressure ABDOMEN _____Pain in the belly _____Severe nausea _____Diarrhea _____Blood in the stools _____Severe bloat (swelling) SKIN AND ALLERGIES _____Severe itching without a rash _____Hives (water blisters) _____Other rashes _____A marked loss or thinning of your hair Mouth reactions _____Lips became swollen _____Tongue became swollen _____Pain in the mouth _____Pain or trouble swallowing A MARKED AND UNINTENDED CHANGE OF WEIGHT Gain of ______pounds Loss of ______pounds OTHER PROBLEMS _____Severe thirst _____Marked frequency of urinating Day_____ Night_____ Both_____ _____Severe changes in menstrual periods More frequent_____ Less frequent_____ They stopped______ _____Severe Joint Pains _____Marked swelling of the legs _____”Low blood sugar” (hypoglycemia) attacks _____Poorer control of my diabetes even while I was on Diet______ Oral Drugs______ Insulin______ OTHER SUSPECTED REACTIONS (Please list) ______________________________________________________________________________ ______________________________________________________________________________ V. CONSULTATIONS AND TEST BEFORE YOU STOPPED ASPARTAME How many PHYSICIANS AND CONSULTANTS did you see in your own community? ______1 ______2 ______3 ______4 ______More How many consultants or clinics did you visit outside of your community? ______1 ______2 ______3 ______4 ______More Were you referred to A PSYCHIATRIST ______Yes ______No A PSYCHOLOGIST ______Yes ______No Another “therapist” ______Yes ______No How many times were you hospitalized BEFORE aspartame was suspected as the cause of your symptoms? _____1 _____2 _____3 ______4 ______5 Did you have any of the following tests BEFORE aspartame was suspected as the cause? If yes, how many? X-rays of the head __0 __1 __2 __3 __4 ___5 CAT scans of the brain __0 __1 __2 __3 __4 ___5 NMR (magnetic resonance) of brain __0 __1 __2 Angiograms (X-rays of blood vessels in the brain) __0 __1 __2 Lumbar puncture (spinal tap) __0 __1 __2 Electroencephalograms (EEG or brain wave test) __0 __1 __2 __3 __4 __5 Stress test of the heart __0 __1 __2 Heart monitor (12 or 24 hours) __0 __1 __2 Upper GI series with barium (X-rays of stomach) __0 __1 __2 Barium enema (X-rays of the lower bowel) __0 __1 __2 Allergy tests (skin, others) __0 __1 __2 Special eye tests __0 __1 __2 Special ear tests __0 __1 __2 HOW MUCH DO YOU ESTIMATE THAT THESE CONSULTATIONS AND TESTS COST? YOU out of your own pocket? $___________________ Your insurance carrier(s) $___________________ VI. REPORTS OF SUSPECTED REACTIONS DID YOU REPORT YOUR SUSPECTED REACTION(S) TO ASPARTAME? ___Yes ___No If “yes,” to whom? _____My doctor _____A consultant _____My family _____The manufacturer of the product _____A public-health department _____The Food and Drug Administration (FDA) _____The Centers for Disease Control (CDC) _____Aspartame Victims and Their Friends _____Another Consumer Organization (Name)____________________________________________________ _____Dr. H. J. Roberts _____Another interested researcher I heard or read about (Name)____________________________________________________ If “yes,” how did you do so? By letter______ By phone call(s)______ Other (state)________________ VII. REACTIONS IN YOUR FAMILY Have other members of your family had problems that they attributed to aspartame? ____Yes ____No If “yes,” how are they related, and how many? _____Husband _____Wife _____Daughter(s)_________________________ _____Son(s)_____________________________ _____Others (who?)____________________________________________________ What kind of reactions did they have?_____________________________________________________ ______________________________________________________________________________ Has any member of your family had Alzheimer’s disease? _____Yes _____No If “yes,” who?_________________________________________________ VIII. YOUR MEDICAL BACKGROUND Did you have ANY of the following conditions BEFORE taking aspartame ...and if so, HOW LONG BEFORE? (Write number of months or years after each condition) _____Migraine _____________ _____Other headaches ____________ _____Depression (feeling blue) ___________ _____Severe “anxiety” ____________ _____Poor vision __________ _____Ear problems ___________ _____Heart disease ___________ _____High blood pressure __________ _____Stomach trouble ___________ _____Bowel trouble ____________ _____Kidney trouble ______________ _____Hives _______________ _____Other rashes (such as psoriasis, acne or lupus) _________________ _____Parkinsonism (shaking palsy) ________________ _____Allergies Hay fever_______________ Asthma ________________ Medicines (such as aspirin, penicillin) (List)______________________ _________________________________________________________ _________________________________________________________ _____Low blood sugar (hypoglycemia) attacks _____Diabetes treated with Diet______ Pills_______ Insulin_______ _____A thyroid problem Goiter_______ Underactive (hypothyroidism)__________ Overactive (hyperthyroidism)___________ _____Arthritis __________ _____A marked weight problem (20 pounds or more)__________ _____An alcohol problem _________long ago __________Current _____A drug abuse problem _________long ago __________Current What drug(s)?_______________________________________________ _____Myasthenia gravis (muscle weakness) How long?______________________ _____Other conditions not listed above___________________________________ ______________________________________________________________ ______________________________________________________________ What OTHER medicines (not listed above) or vitamins were you taking --as well as aspartame-- when your symptoms began? (estimate daily amounts) _____Aspirin _____________ _____Multiple vitamins ___________ _____Vitamin C ___________ _____Vitamin E ____________ _____L-Dopa (for Parkinsonism) ___________ _____Aldomet (for high blood pressure)____________ _____Beta blockers (as Inderal, Corgard, Tenormin, Lopressor) for a heart or blood pressure problem. _____Tranquilizers _________________________________________________________________ _____Others ______________________________________________________________________ Do you smoke cigarettes? ____Yes ____No If “yes,” how many daily? Less than 1/2 pack_____ 1/2-1 pack______ More than 1 pack______ Did you get a severe attack after drinking alcohol while taking aspartame? ____Yes ____No If “yes,” how much? Very little_____ Moderate____ A lot_____ If “yes,” what kind of drink? Wine_____ Beer_____ Liquor_____ IX. OTHER USEFUL INFORMATION Describe and UNUSUAL aspects of your reaction(s) to aspartame._________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have any of your friends had problems with aspartame? _____Yes _____No How many? ____1 ____2 ____3 ____4 If “yes,” what kind of problems? _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you STILL use products containing Aspartame? _____Yes _____No If “yes,” - how much? _______________________________________________________________ - name(s)__________________________________________________________________ If “No,” are you using the following? Sugar ____Yes ____No Honey ____Yes ____No Saccharin ____Yes ____No Other sweetener (name)______________________________________________________ Have you ever heard of the condition known as phenylketonuria (PKU)? _____Yes _____No If “yes”, do you REALLY know what it is? _____Yes _____No If “yes”, has anyone in your family had it? _____Yes _____No Do you believe that the aspartame content of foods and drinks should be required ON LABELS BY LAW? ______Yes ______No If “yes,” would YOU study them? _____Yes _____No Do you think that Congress should do anything about regulating the use of aspartame? ____Yes ____No If “yes,” what? _____________________________________________________________________ THANKS FOR YOUR INTEREST AND TIME!!! FEEL FREE TO CONTINUE OR EXPLAIN IN MORE DETAIL. 6708 Pamela Lane West Palm Beach, FL 33405 FAX 561-547-8008