If you would like more information on
pursuing a claim for damages due to Ephedra or Ma Huang, please fill out the below
form.
There is no charge for this evaluation.
*
Required Fields.
** Click on the
"Disclaimer" link below for Terms
Title*:
First Name*:
MI
Last
Name*:
E-mail
Address*:
(ex. johndoe@anywhere.com)
Home Phone*:
(ex. 505-555-5005)
Work Phone:
(ex. 505-555-5005)
Mobile Phone:
(ex. 505-555-5005)
Street
Address:
City:
State /
Zip:
/
(ex. NY
/ 10005)
* When
did you first learn that Ephedra may have been the cause of your stroke, heart attack or serious medical problem (DATE)?
Date you first learned:
* Who
advised you of this information that Ephedra caused you medical problem (e.g., doctor, T.V., a friend, etc.)?
* What
were you told about the dangers of Ephedra and what did you learn about Ephedra at that time?
Ephedra or Ma Huang Product List
What product containing Ephedra or Mu Huang did you
take? Please select all that may have contained Ephedra or Ma Huang?
During what period of
time were you taking
a product containing Ephedra or Ma Huang?
Start:
End:
* What is your Date of Birth?
What injuries did you
suffer from taking Ephedra or Ma Huang?
High
blood pressure
Heart palpitations
Irregular
heartbeat
Nerve
damage
Insomnia,
nervousness, and dizziness
Gastrointestinal
distress
Hepatitis
Psychosis
Tremors
Headaches
Stroke
Death
Seizures
Heart attack
Did your product containing ephedra or Ma Huang result in a permanent injury? Please describe the type of damages due to ephedra or Ma Huang
Permanent Damage
Temporarily did not feel well
Prior to your taking ephedra, did you have a history of heart disease or stroke?
