EMF Questionnaire

(Electro-Magnetic Sensitivity)

WHICH OF THE FOLLOWING SYMPTOMS DO YOU HAVE?:

	Severity Score 1-10	Frequency (per week)	Constant =C or Intermittent =I	Improves when out of range Y/N	When 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?	YES	NO
Do you have WiFi in your home?	YES	NO
Do you have WiFi at work/school?	YES	NO
Do you carry your cellphone close to your body?	YES	NO
Do you sleep with your cellphone switched on and closer than 2 m from your head?	YES	NO
Do you have a smart meter for electricity?	YES	NO
Are others in your home or workplace affected?	YES	NO

Do you sleep with an electric blanket?	YES	NO
Do you put your phone on flight mode when you are sleeping?	YES	NO
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?	YES	NO
When I check my network, do I pick up neighbouring networks?	YES	NO
Are there electric boxes in my vicinity?	YES	NO

TYPE OF EMR SENSITIVITY

Sensitivity only to high frequencies RW/MW	YES	NO
Sensitivity only to low frequencies ELF	YES	NO
Sensitivity to all EMR frequencies	YES	NO
Sensitivity to dirty electricity, computers, other appliances?	YES	NO

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 fumes	SELDOM	AVERAGE	LOTS
Exposure to passive tobacco smoke	SELDOM	AVERAGE	LOTS
Exposure to glues / paints/ thinners	SELDOM	AVERAGE	LOTS
Exposure to household cleaners & chemicals	SELDOM	AVERAGE	LOTS

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