14: 28 1883332178 0! HRS Hurmtn fierviccs. MED Wnrcu The FDA Safety Information and Adverse Event Program A. 1. Pailent identifier E2. a1Timc Event. or Sm: :1 wuigm - - . . I am ol'B1r' 14:: vs. 9-..- In aansusenm: 1 is 3. AIWEFISE Em, pnooucr pm Chock ha! apuw: 1. 57:! Au-mac Evan: Prunuct Problem Emir [3 ?ruhh:rn with of mt: LEM OR EFSHOFI C?"5flN' For VOLUNTARY of adverse uvcnm. praaduct and use errors Internet fiubmianinn - 2. ac mm.-r.-rso Event {Chuck ms: .:ipp!y} CI I Doses! I-iusullaiirnilafi - Wliai or fsrulungna Daher {moons n1 Muditni Fur,-n13) 3. 381:: :51 Evanuse Error |1c::_::lrad anlarubnlian an Prnvont impairmoniinamugc: filiuvlcoaj -1. Dau: of we Rope-rt rmmadaym; 11x13/2012 'My acn was given a preworkcut product called Craze. Wflen I found him unconscious and unresponsive, I had no idea what had happen. He was taken by EMS to the hospital and after CAT scans and many tests. It. turned cut that the product he drank testad positive to amphetamina and his diagnosis was, ayncope. dehyfization and amphetamine reaction. F?fifi NOV 2.81% sf Efim. amphetamine -poaiive fimur 51151::-gr: ucfing Medical Canfiflivfls fc.r_a.. race. pmgnuncy, smoking and use, . c. paouucr . Product Aveilabic fur Evkluafiofi? {Do not send pmducl to ma) ma Manulmurm cm: 1 EWWUWEWYJ MED PMSE 12/43 Farm OMB ND. 3915-D231. Sec an Trianu ur-ii sauuancn Page 1 1. Nam. Nmfluiaciurcr {from Fat?!) 0 1' 2. W80 or Amuurlt I 3 .3 bee! .. F2 -- L. 3. Gates of unknawfl. fmmno {Dr craze woncou en ma: . xzimfiwt Iv'? 4. magnosis er" Reason far Use 5. Even: Ahatnd Aisur Use Stuppofi or nose Reduced? #1 Mn Ejruo Hanan': 1. Brand Nnmr: craze prewcrkout helps with endurance. swans 3- Mm Rointradutdlanfi . "2 I41 . who i 7 umsn-z Ljifos 1" 9. when 52?. #2 Cammnn Ngme 3. fl' Implanted. Give Dim.' 5. rhlanuraciurer Name. City and State . 6 Image! 2 Lari; 5. ul Hasnh catalog 5 Expiration Date 1 Usamsslicm Serial other a 7. If Give {me Yes N: Craze 23. 2012 Adligossw Single-use Devin: and Rcutc? an re 9. Ye: Stem NO. B. Enter Name and Address of F. OTHER MEDICAL FRDDUCT5 Product names and thm-upy dams roadside cu' oven!) REPORTER (See confidentiality section on back) 2. Hcafih Dccupafinn Yes Na 5. :r you no NOT want your iflefitlly In the plan: an ll': 1111:: box: i-.71 .333' .25- . M: 33 4. Also finpmed Marwlaclurcr 1 rcnmua FDA as on (axes) Submission of -.3 rer.-on does nus constitute an admission that medicai or me product cuuaeca' or eonirlhuled to me O01