Electro Sensitive Questionnaire July 2006


The following outline questions may assist you when compiling your ES health history:

Name & location & previous occupation:  (for the avoidance of duplication. When we compile these details into the document we will code these details, such as F43lon, for female aged 43 and living in London)?

How long have you known you are ES? How did you find this out?

Now that you know about ES how long have you been experiencing ES symptoms?


Have you moved house recently and if so, were you becoming ES at an earlier address and if so what were the triggers? Does anyone else in your household suffer from similar symptoms?

Do your colleagues at work have similar symptoms?


What is your current state of health and how stable is this?

Please list your symptoms, how often do these occur and what are your worst symptoms?

How helpful has your own doctor been and have you been referred by your GP for tests for your ES symptoms?

Please list any treatments either conventional or complimentary that you have tried and which have or has helped you.


How has your life changed since becoming ES, e.g. changes to your career and earning potential, lifestyle, diet, friends, family, travel?

 What are you now regularly unable to do?

What have you done to adapt your life e. g bought corded home phone, stopped using a mobile/computer/wifi internet connection/ microwave oven, other?

Have you shielded your home and or workplace? If so what shielding materials did you use.

Have you learnt anything about being ES that you could share with other sufferers?

Please mention any useful sources of information on ES, web sites, supplements/ clothing/ hand outs, books which we could recommend to other ES.

Would you be prepared to have your case notes included anonymously into a document, which will be used to raise awareness about electro sensitivity? Please write any additional comments on a separate sheet.

Please sign and date this form:

MANY THANKS for your time and we look forward to having more ES news for you soon.

sarahdacre@aol.com or for snail mail post to me at

EMFatic solutions, P O Box 49747, LONDON N20 0XR