Please see the example below:
1. Name: Elsie van Zyl
2. Address: 19 Twistleton Road, Glenwood
3. Contact Number: 079 079 0790
4. Address of closest cell tower: cnr Nicolson and Francois Road
5. Estimated distance of cell tower from your house: 270 metres
6. Relationship of the antennae to your home: The mast is at the bottom of a hill, so the antennae are directly in line with the top storey of the house
7. Do you have more than one cell tower within 500 meters of your home? Yes
8. How many? Five
9. Have you begun to display any of the following symptoms? Please describe the severity (Debilitating, severe, mild, non-existent):
Muscle pain Debilitating
Memory loss Severe
Unexplained weight gain Non-existent
Skin disturbances (a feeling like sunburn) Mild
Mental exhaustion Mild
Confusion and anxiety Mild
Tissue bleeding (such as nosebleeds or gums bleeding). Severe
When did these symptoms start? January 2017
When was the nearest cell mast erected? December 2016
Have these symptoms been reported to a medical professional? Yes
Do you have a formal medical report in this regard? Yes.
Will you be prepared to swear to these facts in an affidavit if is should be necessary? Yes.
If you do not have a formal medical report, we suggest you get one. It is important that underlying conditions that could cause these symptoms be ruled out. The doctor might be called as an expert witness if an individual is going to sue for damages.
The questionnare below can be downloaded and printed from this link: HEALTH QUESTIONAIRE
Please fill it in and return to : firstname.lastname@example.org or to ‘contact’ at EMFSA below.
Please forward to anyone you think might be experiencing health problems related to cell towers,even if they are not in Durban.
On behalf of Durban Anti-Cell Mast Alliance