Crop Circle Research

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Questionnaire on Crop Circles and Health

Please fill in and submit this form if you have ever experienced any mental or physical effects after visiting a crop formation. Please make the details as accurate as possible, but leave blank any fields which you are unsure about. Please feel free to email me more information, if you think it may be of relevance.

All completed forms will be treated in the strictest confidence and not divulged to any third party without your consent.

Thank you for your kind cooperation.

Please identify the crop circle you entered, or explain its whereabouts: 

Weather conditions: 

Date and time of entry:   Date crop circle was created (if known): 

How long did you stay in, or around the circle? 

Before the visit, what did you think was the origin of crop circles?

      Hoaxers          Atmospheric phenomena 
Paranormal agency eg. UFOs/Earth Energies
Other (please state)

What made you visit the crop circle in the first place? 

Are you taking any prescribed medicine? If so, please state. Yes No
If yes, briefly describe;

Did you have any longstanding or recent health problems when you entered the circle? If so, please describe these.

If you answered yes to the above question, did you find any beneficial or detrimental effects to your condition after visiting the crop circle?

Do you have any metal/amalgam/gold fillings in your mouth?
Yes No

Have you ever witnessed any paranormal or pyschic events before entering the crop circle?
Yes No

Have you ever witnessed any paranormal or pyschic events since entering the crop circle?
Yes No

Did you experience any change (a) PHYSICAL or (b) MENTAL/EMOTIONAL as a result of your crop circle visit? If so, please describe. 

How long did the effect last? 

Did these effects vary as you moved around the formation? 

Representing your feeling of well being, please indicate how best describes how you felt BEFORE and AFTER your visit. Select a rating out of 10 with 5 being normal, or indifferent. If you felt worse, enter 1 or if you felt better enter 10.
Before After

Did you observe anything else unusual, eg. taste or smell, effects on photographic equipment, animal behaviour, recording equipment, lights, etc? 

May I quote your experiences? Yes No

If yes, would you prefer to be anonymous? Yes No

Would you be prepared to be interviewed about your experience? Yes No

Name: Mr Mrs Miss Ms






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