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Information about the Unseen Environment
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SYMPTOM REPORT
This Survey is based on symptoms from the Austrian Medical Society electro-hypersensitivity syndrome (EHS) questionnaire. Additional common complaints from Sedona residents have been added.
Please fill out the health record report first to establish an ID .
You may return to this page as often as you like to record how you feel, and what symptoms you may be experiencing during the day. Don't forget that reporting feeling good, indicating when something ISN'T happening is also valid data.
You have the option whether or not to make your symptoms public.
Please use your unique ID . Your ID can be your real name, a made-up name, numbers, or combination so that your data will be anonymous if you prefer.
Email (optional)
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May we make your report public so others can see?
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Yes
No
Please create OR add your existing an ID so you can update data
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Date: YY/MM/DD
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AUSTRIAN MEDICAL SOCIETY AND OTHER SYMPTOMS, CHOOSE ALL THAT APPLY
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Anxiety
Brain Fog
Chest tightness
Depression
Dizziness
Ear Pressure sensation
Fatigue
Headache
Head Pressure
Irritability
Memory, poor short term
Opthalmic migraine
Seizure
Sleep Disturbance
Words, difficulty finding
None of the above
Neurological/Emotional: Choose as many as have increased in the last year.
ADDITIONAL SUBJECTIVE SYMPTOMS
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Ambition/motivation, lack of
Chronic Fatigue
Fall
Overwhelmed sensation
Sleep quality poor
Slept during day
Words, forgetting
Your Local time
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PHYSICAL SYMPTOMS CONTINUED, CHOOSE ALL THAT APPLY
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Allergies increased
Arthritis, increase
Blood pressure, high
Blood pressure, low
Blood sugar problem
Chest tightness
Eyes, burning sensation
Eyes, difficulty focusing
Eyes, other (floaters, flashes)
Fatigue, extreme
Headache
Head Pressure
Heart Palipitations
Feeling hot, sweating
Lightheadedness
Muscle cramps
Muscle soreness
Muscle weakness
Night sweat
Numbness, neuropathy
Skin Rash
Physical symptoms: Choose as many as have INCREASED since April 2014
Other symptom(s):
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Other Symptom(s):
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Please describe
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Please describe
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Submit