Disclaimer: Answers to all questions are voluntary. Confidentiality of data will be maintained. If sufficient responses and data are received, the data may be used for research purposes. You need to fill in all the details again if you exit without submitting. Please fill out only one form for person. If any friend or member of your family is affected or sick, please fill out a separate form for each individual.
If you want to keep a health diary for your family, please download the PDFs on the left by clicking the links and saving them to your computer.
|Health Effects – Heart
Health Effects – Lungs
|If you have any questions regarding this survey, please contact:
Howard P Gamble, MPH
Wheeling-Ohio County Health Department
City-County Building, Room 106, 1500 Chapline Street, Wheeling WV 26003
Our overall goal: To provide an avenue for voluntarily sharing real and perceived environmental health concerns. Our overall goal is to also empower the community with resources where individuals can maintain a health diary to keep track of their personal and family’s health.
Estimated time to complete: 15-20 minutes.
Michael McCawley, PhD, WVU
Somu Chatterjee, MD, MPH, WOCHD
The Diary and Environmental Health Survey Questionnaire (EHSQ) were developed as part of Priscah Mujuru, Dissertation Study: The Allegheny County Short-term Air Pollution Effects (SHAPE) Study on the Elderly, April 2005. The EHSQ format was modified from Rosero Zareba et.al (1999), and the Asthma Diary from Delfino et al (2002, 2003)
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