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.

View Survey Data


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:

Somu Chatterjee, MD, MPH

Regional Epidemiologist
Wheeling-Ohio County Health Department
City-County Building, Room 106, 1500 Chapline Street, Wheeling WV 26003
Email: somu.k.chatterjee@wv.gov

Health Survey

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.

 Yes, I declare that the information disclosed here is true to the best of my knowledge. (Required)

 Yes, I authorize the use of data provided here for research purposes.

Your Name (optional):

Your Street Address (Use 911 compatible address. No P.O. Box please):

Your State:

Your County:

Your Zip:

Your Email Address:

Phone (optional):

Do you want us to contact you in the future for research purposes?
 Yes No

Age:

Sex:  Male Female

Do you live near a gas well site or compressor station?  Yes No

If yes, what is the shortest distance to the gas well site or compressor station (in feet/miles/meters/kilometers)?
Distance:

 

Health Questionnaire


Question 1: Have you ever been told by a physician that you have or had a LUNG DISEASE?
 Yes No

If yes, please write the name of the disease or diseases below:
Lung Disease 1:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Lung Disease 2:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Lung Disease 3:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Question 2: Have you ever been told by a physician that you have or had a HEART DISEASE?
 Yes No

If yes, please write the name of the disease or diseases below:
Heart Disease 1:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Heart Disease 2:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Heart Disease 3:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Question 3: Have you ever been told by a physician that you have or had HYPERTENSION?
 Yes No
• When was it diagnosed?
• Have you visited the ER for this disease?  Yes No
• Are you under treatment?  Yes No
• Have you increased or decreased dose of medications?  Yes No


Question 4: Have you had any other disease?
 Yes No

If yes, please write the name of the disease or diseases below:
Other Disease 1:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Other Disease 2:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Other Disease 3:

    • When was it diagnosed?
    • Have you visited the ER for this disease?  Yes No
    • Do you still have the disease?  Yes No
    • Are you under treatment?  Yes No
    • Has there been a revision of, or a change in diagnosis?  Yes No
    • Have you increased frequency of treatment?  Yes No
    • Have you increased or decreased dose of medications?  Yes No

Question 5: Are you allergic to anything?  Yes No
If yes, what are you allergic to?

Allergy 1:
Allergy 2:
Allergy 3:
Allergy 4:
Allergy 5:


Question 6: What factors aggravate your respiratory, heart problems, allergy or asthma?
 Cold Air Humidity Exercise Medication Change of Seasons Dust or Animal Dander Other

Explain:


Question 7: Do you or did you have trouble sleeping?  Yes No
If yes, have you discussed it with a physician?  Yes No


Question 8: Which of the following do you think is disturbing your sleep the most?
 Age Related Noise Light Other Not Applicable


Question 9 (optional): Details of family members in your household who have been sick since January 2006/2010 and seen by a physician. Please fill out a separate survey for each family member.
 Children under 1 year Children 1 year to less than 5 years Children 5 years to less than 18 years Children 18 years to less than 60 years Above 60 Pregnant


Question 10: Have you noticed any changes in road conditions in your region since 2010?
 Yes No

If yes, explain:


Question 11: Do you smoke?  Yes No


Question 12: Do you work in the gas industry?  Yes No


Question 13: What is your occupation?


Additional Comments:

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Credits:
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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