Aspartame Consumer Safety Network
P.O. Box 2001
Frisco, Texas 75034 U.S.
Phone/FAX: 214.387.4001

Is Aspartame Affecting You?

Name: 

Street:

City:

State/Zip:

Country: Tel: ( ) (res.) Tel: ( ) (work)

FAX: Email address:

Age:                 Sex:

Q.  May we have permission to publish your data to help others?

A.

Q. Name medical problems YOU experienced while using aspartame (tm NutraSweet/tm Equal).

A.

Q. Have you been diagnosed with any form of malignancy that coincided with your aspartame use?
(Aspartame caused brain, uterine and mammary tumors in lab animals in the original tests.)

A.

Q. Did your symptoms go away or diminish when you stopped using the sweetener?

A.

Q. How long have you been Aspartame-free?

A.

Q. Did you see a Doctor about any of these symptoms?

A.

Q. Did your Doctor think it could be related to aspartame?

A.

Q. Did your Doctor advise you to stop using aspartame?

A.

Q. Did you use aspartame while pregnant? (Give approx. amounts.) (Aspartame changes DNA and has
caused birth defects in lab animals.)

A.

Q. Did you report your symptoms to the FDA (Food & Drug Admin.) or any other group?

A.

Q. Name the specific products) containing aspartame you were consuming when you experienced
these symptoms. (Brand names.)

A.

Q. On the average, what quantity were you consuming (how often, how much each time, etc.)

A.

Q. Did you ever feel addicted to your sweetener? (Describe)

A.

Q. How long had you been consuming aspartame before you began to experience any symptoms?

A. FOR THOSE CONCERNED ABOUT WEIGHT: Did you begin using products with aspartame when 
you began a restricted calorie diet or joined a weight loss program?

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:

Q. Did your Doctor or a Registered Dietitian tell you to use aspartame?

A.

Q. Any trouble controlling blood sugar levels while using aspartame? (Explain)

A.

Q. Did using aspartame affect the types of food you selected to eat?

A.

Q. How?

A.

Q. Did you contact the American Diabetic Association about your problems w/aspartame? If yes,
what was their response?

A.

Q. Did aspartame affect your desire for sweet tasting food or drink?

A.