Quebec Medical 2001 / Urgence Manif
Tear Gas and Health Survey


Introduction Due to the heavy amount of tear gas used by the police in Quebec City during the FTAA protests, we are examining the health consequences by people who were exposed. Please understand too, that sometimes, the stress of an intense event like the Quebec protests might also cause similar symptoms or illness.


Instructions Please complete the following form. If you are uncomfortable answering the questions, leave them blank; none of the questions are mandatory. After completing all the questions, click on "COMPLETE", to send the form. The completed form will be sent to the survey coordinator via email, and therefore a warning will pop up to confirm that you want to send the results of the survey via email. Click yes to send, and the survey will be sent. Any questions, comments or other feedback may be placed in the "additional notes" box. Thank you for taking the time to fill out the survey.

You may download a printable version of this survey you can mail to us here. (Rich Text Format 7K)

About You

Date Sex  Male Female
Age 11 yrs or less 12-20 yrs 21-40 yrs 41-65 yrs 66 + yrs

Did you live in Saint-Jean Baptiste or le Basse Ville in Quebec City that was exposed to tear gas?
YesNo

Questions

1a)  Were you exposed to any tear gas or tear gas residue during or after the protests?
YesNo

1b)  If Yes, how long and how close to the tear gas you were exposed. (Could you see the tear gas canister? How far away was the tear gas "cloud" visible?). Did your home, food or workplace get contaminated?

2a)  If your home or workplace was contaminated by tear gas, how long did the tear gas residue take to disappear?


2b) Did you evacuate your home because of exposure to tear gas?
YesNo

3a)  Did you have any health problems or unusual symptoms (beyond any immediate coughing or tearing) you believe resulted from your exposure to tear gas?
YesNo

3b)  If yes, did you have symptoms or problems with any of the following?
Headache Poor Concentration Unusual Fatigue Nausea
Irregular or unusual menstruation Muscle fatigue, pain or cramps Vomiting Digestion/Elimination
Flu or Cold Respiration or Breathing Eye or Vision Skin
Other
3c)  If yes, how long did each symptom last?
Still have them        Other  

4)  Do you feel recovered now?
YesNo

5a)  If you are female, did you have regular menstrual periods before the tear gas exposure?
YesNo

5b) If yes, did your menstrual cycle change after your exposure?
YesNo

5c)  If yes, how has it changed?


6)  Were you pregnant when exposed to the tear gas?
YesNo

For Everyone:

7)  Did you lose time from work, school or other activities because of your health symptoms?
Yes  How long?    No

8a)  Did you see a health specialist or visit a health clinic/hospital about your symptoms?
YesNo

8b)  If yes, what were the results?


8c)  Please indicate any therapy or medication you used or were perscribed :


9)  Did you wear protection when exposed?
Gas Mask    Respirator    Bandana    Eye Goggles    Non-absorbent Clothes
Other:

10) Did you wear contact lenses unprotected by goggles or a gas mask when exposed?
YesNo

11) Besides any exposure to tear gas, were you stressed during the time of the Summit?
Not Stressed A little Stressed Moderately Stressed Very Stressed

12) Additional notes


If you would be willing to be publicly interviewed about your health, please check here

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