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Action Form: Are Computers Hurting Your Health ?

If you had a medical diagnosis, how difficult was it to get a correct one?
Don't Know Easy Difficult Impossible

What kind of experience have you had with the medical profession?
Don't Know Bad Good Excellent

If you used a alternative practitioner, what kind of experience did you have?
Don't Know Bad Good Excellent

What did you find worked for you?
Stress Reduction Vitamins Herbs Diet Change
Prescription Drugs Exercise Time-Off Body Work

Who would you like to be informed about this subject?
Medical Associations Government Regulatory Agencies Elected Representatives Drug and Supplement Manufacturing Companies


What following conditions do you think apply to you. (Check anything that might apply)

angina back pain backache
birth defects blurred vision brain cancer
burning burns Carpal tunnel syndrome
CATARACTS chest pain childhood leukemia
childhood cancer diarrhea difficulty focusing
dizziness epileptic seizure eye irritation
eye burns eye complaints eye problems
eye injury generalized fatigue headache
heart disease heartburn hemorrhoids
high blood pressure irritated eyes itching
lack of concentration leukemia loss of appetite
lymphoma lymphoma in children memory loss
muscular aches numbness phlebitis
pollutants pollution postural problems
repetition strain injuries repetitive strain injuries risk of leukemia
shoulder pain sick building syndrome strain injuries
stroke tendonitis twitching eyelids
ulcer uncorrected vision problems varicose veins


Check off any of the following items that you ingest.

amines COMPU-LENZ insomnia
PCB photochemical oxidants rashes


Check off any of the following therapies or procedures you use.

acupuncture job satisfaction massage
scheduled breaks


Make your imput count. The information you submit will be compliled with all other submissions and used to activate for positive change in women's health.

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