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Safe Wireless Initiative
January 26, 2008


Safe Wireless Electro-sensitivity Evaluation Profile
(SWEEP)

The purpose of SWEEP is to provide an objective assessment of the degree of electro-magnetic radiation related disease risk the subject has sustained, based on lifestyle, present symptoms and susceptibilities.

Instructions:

Please answer each of the following questions, based on how you feel today, by checking either "yes" or "no".
The Evaluation Table to help you interpret your results appears at the end of the questionnaire on page 5.

1. Are you over the age of 50?
Yes
No

2. Are you under the age of 18?
Yes
No

3. Are you more than 20 pounds over your ideal weight?
Yes
No

4. Do you experience abnormally frequent colds?
Yes
No

5. Do you experience abnormally frequent allergies?
Yes
No

6. Do you have heart disease in your immediate family?
Yes
No

7. Do you have cancer in your immediate family?
Yes
No

8. Do you have diabetes in your immediate family?
Yes
No

9. Have you been a regular smoker in the past five years?
Yes
No

10. Do you currently have more than two drinks per day?
Yes
No

11. Do you use recreational drugs?
Yes
No

12. Do you exercise less than once per week?
Yes
No

13. Do you eat meat more than four times per week?
Yes
No

14. Do you eat near your bedtime more than twice per week?
Yes
No

15. Do you regularly not sleep through the night?
Yes
No

16. Do you have less than two servings of fruits/veggies/day?
Yes
No

17. Do you drink less than eight glasses of water per day?
Yes
No

18. Do you eat "fast food" more than four times per week?
Yes
No

19. Do you drink more than ten cups of coffee per week?
Yes
No

20. Do you work in a high-stress job?
Yes
Yes
No

21. Do you work around toxic chemicals?
Yes
No

22. Do you work around people with infectious diseases?
Yes
No

23. Do you work in extreme heat or cold?
Yes
No

24. Do you regularly use a mobile telephone?
Yes
No

25. Is your mobile phone use more than 500 minutes/month?
Yes
No

26. Did you use a mobile phone regularly prior to 1996?
Yes
No

27. Do you live near mobile phone transmission towers?
Yes
No

28. Do you live near high tension power lines?
Yes
No

29. Do you have wireless internet in your home?
Yes
No

30. Do you use cordless telephones in your home?
Yes
No

31. Do you have a cordless phone station in your bedroom?
Yes
No

32. Do you use a microwave oven more than 5 times weekly?
Yes
No

33. Do you have more than three televisions in your home?
Yes
No

34. Do you use an electric blanket more than half the year?
Yes
No

35. Do you sleep within 20 feet of an electrical fuse panel?
Yes
No

36. Do you use a hairdryer more than four times per week?
Yes
No

37. Do you live in a densely populated urban area?
Yes
No

38. Are you in a WiFi environment more than 5 times weekly?
Yes
No

39. Do you use a mobile phone more than 5 hours daily?
Yes
No

40. Do you use a cordless phone more than 5 hours per day?
Yes
No

41. Do you regularly talk on a mobile phone in your car?

Yes
No

42. Do you regularly use a wireless "blackberry" or PDA?
Yes
No

43. Do you regularly use a wireless laptop computer?
Yes
No

44. Do you work with or near radar?
Yes
No

45. Do you work near electrical transformers?
Yes
No

46. Do you work near high tension power lines?
Yes
No

47. Are you in a brightly lit room more than 5 hours daily?
Yes
No

48. Do you stay in a hotel more than five nights per month?
Yes
No

49. Do you work with power tools?
Yes
No

50. Are you an airplane pilot?
Yes
No

51. Do you travel by air more than five flights per month?
Yes
No

52. Do you have headaches more than three times per week?
Yes
No

53. Do you have nausea more than two times per week?
Yes
No

54. Do you ever have unexplainable anxiety attacks?
Yes
No

55. Do you feel disoriented more than once per day?
Yes
No

56. Do you feel dizziness more than once per day?
Yes
No

57. Do you ever experience feelings of "worthlessness"?
Yes
No

58. Do you ever suffer from blurred vision?
Yes
No

59. Do you ever feel unexplained fatigue during the day?
Yes
No

60. Do you ever feel burning in your ears?
Yes
No

61. Do you ever hear ringing in your ears?
Yes
No

62. Do you ever feel numbness/tingling in your hands or feet?
Yes
No

63. Do you ever feel your skin crawling?
Yes
No

64. Do you ever feel unexplainable pain?
Yes
No

65. Do you have appetite changes more than once per week?
Yes
No

66. Do you experience daily mood swings?
Yes
No

67. Do you ever experience unusual heart rhythms?
Yes
No

68. Do you ever experience panic attacks?
Yes
No

69. Do you ever feel stress for no apparent reason?
Yes
No

70. Do you ever have unexplainable nosebleeds?
Yes
No

71. Do you ever have unexplainable redness of the eyes?
Yes
No

72. Do you ever have unexplainable burning and itchy eyes?
Yes
No

73. Do you ever have difficulty remembering things?
Yes
No

74. Do you ever have difficulty focusing?
Yes
No

75. Do you experience sleep pattern changes?
Yes
No

76. Do you ever have unexplainable rashes or dry skin?
Yes
No

77. Have you experienced an increase in colds or flu?
Yes
No

78. Do you have personal relationship problems?
Yes
No

79. Are you generally unhappy?
Yes
No

80. Do you have or have you had brain cancer?
Yes
No

81. Do you have or have you had eye cancer?
Yes
No

82. Do you have or have you had acoustic neuroma?
Yes
No

83. Do you have or have you had lymphoma?
Yes
No

84. Do you have or have you had leukemia?
Yes
No

85. Do you have a hypo- or hyper- thyroid condition?
Yes
No