Electromagnetic and Microwave Radiation Health Survey for the Greater Sedona Area sponsored by Sedona Smart Meter Awareness (www.SedonaSmartMeterAwareness.com) - Second Survey

INSTRUCTIONS:   This is the second of the series.  If you have not completed the first one, please go to https://www.surveymoz.com/s/110649SQOSD to complete the first survey and then come back for this second one.
 
This health questionnaire has 10 questions.  You will be invited to complete this questionnaire three times: once for the first survey, and then this one as smart meters are being put in Sedona starting April, 2014, and then within the next few months after smart meters installations are complete.  The purpose of the questionnaire is to determine any changes in your health status during this period.  While the results will be published your identity will remain confidential.  We ask you to identify yourself (with initials) and your Zip Code only so we can compare your first, second and third questionnaire responses.  If you are a business location, please feel free to send questionnaires for all employees willing to participate.
 
Providing your contact information will enable us to anonymously plot your location on a Sedona map to see if there are clusters around cell phone antennas and towers, high intensity electromagnetic antennas, or to identify other areas of concern including clusters of electromagnetic problems.
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1. * Check as many as apply:
*

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2. Document the frequency and severity of any of the following during the this month after smart meter installation. Check as many as apply:
                                                                      Frequency                                                                                                 Severity

raresometimesoftenmildmoderatesevere
headache
memory difficulties
dizziness
dry eyes
blurred vision
sleep disturbances
irritability
anxiety
depression
difficulty concentrating
fatigue
brain fog
difficulty in finding words
weight gain
high pitch buzz/ringing in the ear
heart palpitation
skin rash/burning
bleeding
muscle and joint pain
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3.
Do you currently have any of the following medical conditions and have symptoms changed during the past month?
                                                                        Medical condition                                                 If "yes", symptoms are...than normal.
*

YesNobettersameworse
Amyotrophic Lateral Sclerosis
Alzheimer's Disease
Asthma
Cancer
Cataracts
Diabetes
Heart Ailment
High Blood Pressure
High Blood Sugar
Immune System Disorders
Multiple Sclerosis
Parkinson's Disease
Seizures
Stroke
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4. Check which of these electronic devices you use in your home and/or at work and the frequency of use.
                                                                                         at home                                                                                    at work
*

neversometimesoftenneversometimesoften
cellular phone
cordless phone
wireless computer network
microwave oven
baby monitor
other wireless devices (speakers, mouse, keyboard, printer, etc.)
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5. Please provide your initials (or pseudo initials) and your Zip Code so that your answers to the first, second and third questionnaire can be compared. *

*
*
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6. Today's Date *

   DD/MM/YYYY 
 
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7. Gender: *

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8. Age: *

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9. (Optional) Your contact info:

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10. (Optional): Additional comments about your health can be provided here.