Private Health Survey for Victims of Aliso Canyon Gas Blowout of 2015

The Environ. & Medical Fallout Task Force (https://www.cancerincytes.org/task-force-gas-blowout)

Please fill this out for yourself or each person in your family.

The information in this survey will serve two purposes.

(1) Track the occurrence of diseases to better help victims understand their risk of future diseases or worsening disease.

(2) Assess the logic of results from any health studies sanctioned by the funds from SoCal Gas.

***Only 30 Short Questions (10-15 minutes)***

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* 1. What is your gender?

Female

Male

Other

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* 2. What was your age range in 2015?

1-10

11-20

21-30

31-40

41-50

51-60

61-70

70+

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* 3. Did you live in Porter Ranch for any period of time between November 2015 and November 2016?

Yes

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* 4. Did you live in the San Fernando Valley for any period of time between November 2015 and November 2016? (East of Glendale, CA, and East of Downtown Los Angeles means “No”)

Yes

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* 5. Recurring Nosebleed - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 6. Headache - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 7. Heart Palpitation - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 8. Skin Rash - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 9. Swelling of Throat/Face - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 10. Migraine - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 11. Loss of Vision - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 12. Blurry Vision - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 13. Vomiting - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 14. Diarrhea - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 15. Abnormal Menstruation - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 16. Low Libido - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 17. Painful Urination - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 18. Abnormal Urinary Habits - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 19. Urinary Tract Infection - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 20. Asthma - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes

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* 21. Difficulty Breathing - Did you suffer from this during the 2015 to 2016 gas rupture?

Yes