Erythritol Intake Form

Did you or a loved one suffer a cardiovascular event (e.g., heart attack, blood clot, or stroke) after regularly eating or drinking products that contain erythritol?

Yes

Personal Information (for you or your loved one)

Name:(Required)

First Last

Email:(Required)

Phone:(Required)

Address

Relation to the person who suffered the heart condition:

What cardiovascular event did you or your love one suffer?

Heart Attack

Blood Clot

Stroke

When did this happen?

During the five-year period prior to the cardiovascular event, what products that include erythritol did you or your loved one eat or drink?

Please provide details and how much was consumed.

During the five-year period prior to the cardiovascular event, were you or your loved one on a specific diet?

If yes, what diet?

During the five-year period prior to the cardiovascular event, where did you or your loved one regularly shop for food and groceries?

Family History

Do you or your loved one’s parents or siblings have a history of heart diseases? Please describe:

Is there any additional information that would help us evaluate your case? Please describe:

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Thank you very much for providing this information.