EMR Symptoms Form

Title

First Name *

Last Name *

Age

Email Address *

Work Phone Number

Home Address

City

State

Zipcode/Postcode

Country

What triggers your symptoms?
Power lines
Appliance
Mobile Phone
Wireless Computer
Phone Antenna

Other triggers (please specify)

Please describe your symptoms

Are these symptoms relieved when you are away from the source?

How long have you had these symptoms?

Do you have any of the following conditions
Fibromyalgia
Chemical sensitivity
Chronic fatigue syndrome
Asthma
Tinnitus
Irritable bowel syndrome
MS

Prove you're not a robot *

Do you experience symptoms from EMR?