To help ASEQ-EHAQ know how many members suffer from electro hypersensitivity, to understand the social and economic effects of this condition and to find out how people cope, you are invited to fill in this questionnaire.

The information you provide, which will remain anonymous, will assist us in identifying the burdens of this condition and to identify needed support and services for people suffering from this illness.

Your express permission is required to place your information into a database. There is an identifier number attached to this questionnaire. Only ASEQ-EHAQ will have access to this information and will place this in a secure location not to be entered into or stored on any computer.

Since many people with this condition cannot use a computer due to the electro magnetic fields, kindly print this questionnaire and hand it over to friends or family who may be affected so that they can fill it out.

Your signature at the end of this questionnaire will mean that you have given your permission to ASEQ-EHAQ to place the information provided by you into a database.

Please click to download and fill out this questionnaire (word doc)

email it to: office@aseq-ehaq.ca
or
Post your completed copy to:
ASEQ-EHAQ, 6 Trianon, Dollard-des-Ormeaux, Québec H9A 2H8