Fluoride testimonial

This form is designed to collect data for a Fluoride Testimonials page – a database of adverse health effects possibly caused by fluoride or fluoridation chemicals in Australia.

Before completing this form, please note the following:

Your full name and e-mail address will NOT be published
Your initials, age and post code WILL be published, for example: JC/48/2350
All other data provided may be published

First Name *

Last Name *

Age *

Post Code *

Email *

Please provide a brief list of symptoms possibly caused by fluoride

What are the main sources of fluoride possibly causing these symptoms?

When did you first notice these symptoms?

How long after exposure to fluoride did the symptoms commence?

How long did the symptoms continue?

If the symptoms reduced, was this due to reduced exposure to fluoride?

Have your symptoms been assessed as being caused by fluoride? If yes, who assessed you?

Have you taken any actions to reduce the symptoms?

Have you informed your doctor or health practitioner about your symptoms?

Have you informed any other authorities?

Please provide details of any current or past green or black tea consumption, including age, frequency, duration, type of tea

Please provide details of any current or past use of fluoridated toothpaste and fluoride dental treatments

Any other details you would like to provide?

Declaration

I declare, to the best of my knowledge, the details provided above are true and correct.

Your name (as signature)

Date submitted

If necessary can we contact you to discuss your case further?

Name