Crew Health Survey

Please answer as many relevant questions as you can. Questions with a (*) are required.

Are you: (*)

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Name of airline: (*)

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Age: (*)

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Gender: (*)

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Country of residence: (*)

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Do you smoke: (*)

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If Yes how many do you smoke a day:

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How many years have you flown with your present airline: (*)

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How many years have you flown with other airlines:

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In the last 12 months which contract were you on: (*)

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Which fleet are you on: (*)







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In the last 12 months which rank did you operate in most: (*)






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How many years approx have you worked on:

747

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777

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767

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757

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737

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Airbus

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BAE 146

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Other

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(please specify a/c type)

How many times have you reported sick in the last 12 months: (*)

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How long have you been off sick in total in the last 12 months: (*)







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Eye irritation

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Blurred or altered vision

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Nose bleeds or nose irritation

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Sore throat

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Hoarseness or voice loss

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Shortness of breath

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Chest pain

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Heart racing or palpitations

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Nausea

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Vomiting

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Diarrhoea

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Dizziness

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Fainting

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Loss of balance or coordination

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Shaking or tremors

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Numbness or pins and needles in face, hands, feet

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Severe headache

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Confusion, difficulty finding words, counting, thinking

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Dyslexia with no previous history

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Difficulty concentrating

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Memory loss

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Seizures, loss of consciousness

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Unusual tiredness or fatigue

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Anxiety or stress

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Depressed mood

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Apathy

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Irritability or mood swings

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Sleep disturbances, inability to stay awake or go to sleep

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Restlessness

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Feeling of being remote

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Alteration in taste or smell

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Chemical sensitivity eg alcohol, caffeine, food additives

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Pains in legs, feet, back

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Pains in shoulder, arms, hands

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Joint pains

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Generalised muscle aches

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Muscle weakness

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Skin rashes

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Have you been diagnosed with any of the following since you started flying? Please mark which ones:





























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please specify type of Cancer

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please specify Allergies

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please specify other illnesses

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Any additional information you think may be relevant:

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Would you like to receive further information on Aerotoxic Syndrome?
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Crew Health Survey

If you are a pilot or cabin crew please take part in our survey:

Online form

UPDATED - Download the results from the first year of the survey:
Survey results