EMF Questionnaire

(Electro-Magnetic Sensitivity)

WHICH OF THE FOLLOWING SYMPTOMS DO YOU HAVE?:

 Severity Score 1-10Frequency (per week)Constant =C or Intermittent =IImproves when out of range Y/NWhen did symptoms begin?
Headache or migraine     
Pressure in the head     
Pressure in the ears     
Tinnitus (ringing in ears)     
Eye focus problems/blurry vision     
Pain or pressure in eyes     
Brain fog     
Sleep difficulties     
Anxiety     
Depression     
Fatigue     
Blackouts     
Dizziness     
Heightened sensitivity to noise/light     
Irritability/aggressiveness     
Other nervous symptoms     
Immune problems     
Flu-like symptoms/fever     
Muscle tingling/twitching     
Pins & needles in hands and feet     
Muscle spasms     
Joint/muscle pains     
Hand/leg dysfunction     
Sore hip bones [women]     
Weakness     
Oedema/swelling     
Thyroid dysfunction/swelling     
Hair loss     
Heart palpitations     
Slow or fast heart rate     
Chest tightness/pressure     
Low or high blood pressure     
Shortness of breath/asthma     
Hoarse voice/cough     
Sinus problems     
Thirst/Dehydrated skin/lips/mouth/eyes     
Facial flushing     
Metallic taste in mouth     
Sensation of internal burning     
Internal bleeding     
Abdominal pain     
Nausea     
Shooting pains in stomach     
Digestive disturbances     
Incessant burping     
Impaired liver function     
Sore kidneys     
Skin rash/eczema     
Itching/tingling/burning sensation on skin     
Sudden lumps/moles     
Lymph node swelling     
Painful ovaries/testes     
Changes in menstrual cycle     
CANCER     
Other symptoms:           

Do your symptoms/problems date back to any particular trauma / illness / incident? 

Details:

EXPOSURE TO EMR (electro-magnetic radiation)

Proximity of nearest cellphone antenna/mast 
Proximity of WiFi router to your bed/workstation 
Do you use a DECT (cordless) phone?YESNO
Do you have WiFi in your home?  YESNO
Do you have WiFi at work/school?  YESNO
Do you carry your cellphone close to your body?YESNO
Do you sleep with your cellphone switched on and closer than 2 m from your head?YESNO
Do you have a smart meter for electricity?YESNO
Are others in your home or workplace affected?YESNO    
Do you sleep with an electric blanket?YESNO
Do you put your phone on flight mode when you are sleeping?YESNO
Are there plug points close to my bed, especially close to my head?YES (Number of days off=      )NO
Does my car have blue tooth or smart technology?YESNO
When I check my network, do I pick up neighbouring networks?  YESNO
Are there electric boxes in my vicinity?  YESNO

TYPE OF EMR SENSITIVITY

Sensitivity only to high frequencies RW/MWYESNO
Sensitivity only to low frequencies ELFYESNO
Sensitivity to all EMR frequencies  YESNO
Sensitivity to dirty electricity, computers, other appliances?YESNO

CO-MORBIDITIES (conditions often associated with EMS)

Fibromyalgia  
Trauma to spine or head  
Multiple chemical sensitivities  
Heavy metal toxicity  
Dementia  
Parkinson’s disease  
Multiple Schlerosis  
ME or Chronic fatigue syndrome  
Autism  
ADHD  
Diabetes  
Cancer  

EXPOSURE TO CHEMICAL TOXINS

How many mercury dental fillings have you had in the past?                                     If replaced, when?
How many mercury dental fillings remain?
Do you have evidence of, or suspicion of, mould or damp in your daily environment?
Have you had any serious toxic exposures in the past?
Do you live in a crop-spraying or farming area [including vineyards]?
Exposure to exhaust fumesSELDOMAVERAGELOTS
Exposure to passive tobacco smokeSELDOMAVERAGELOTS
Exposure to glues / paints/ thinnersSELDOMAVERAGELOTS
Exposure to household cleaners & chemicalsSELDOMAVERAGELOTS

If you have scored high on the yes’s and Lots, chances are that you are suffering from EMF sensititvity.