(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.