Registration for Individuals with Environmental Sensitivities

Individual Registration

Name (optional)

Email Address (optional)

Year of birth *

(yyyy)

Gender * MaleFemaleOther Gender

State * VICNSWACTQLDSANTWATAS

Postcode *

Do you have.... *

MCS (multiple chemical sensitivities)

EHS/ES (electromagnetic hypersensitivity/electro-sensitivity)

CFS/ME (chronic fatigue syndrome/myalgic encephalomyelitis)

Lyme Disease and/or its co-infections

Biotoxin-related illness

Fibromyalgia

Food sensitivities

Fragrance sensitivities

Other

more than one box can be checked

If you selected other, please specify

In which year did your condition develop? (if known)

(yyyy)

Have you been provided a diagnosis by a medical practitioner? * YesNo

If you have difficulty or suffer hardships in any of the following areas due to your condition?

Medical Care

Housing

Education

Employment/ Income

Social Services

Accessing Public Buildings

Relationships/ Social interactions

Other

None

more than one box can be checked

If you have selected other hardship, please specifify

Comments (if any)

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Please note ANRES cannot and will not be in contact with you based on this information. However, if you have no objections to being contacted or informed about results or future projects then please leave your details here.