Personal History – PFAS Justice Legal Network

Please indicate which Community you currently live in:

When did you become a Resident of the Community?

Did your health change in any significant way since you became a Resident of the Community?

Yes No

Your Gastro-Intestinal Issues

Gastro-Intestinal Issues:

Your Recurrent Diarrhea

Recurrent Diarrhea:

How often do you experience recurrent diarrhea?

Your Monthly

Monthly

Your Ulcerative Colitis

Ulcerative Colitis:

Your Recurrent Acid Reflex

Recurrent Acid Reflex:

Your Liver Cancer

Liver Cancer:

Your Recurrent Nausea

Recurrent Nausea:

Your Irritable Bowel

Irritable Bowel:

Your Tumor/Cancer of

Tumor/Cancer of:

Your Esophagus

Esophagus:

Your Stomach

Stomach:

Your Other Tumor/Cancer

Other Tumor/Cancer:

Your Non-cancer Liver Disease

Non-cancer Liver Disease:

Your Other Non-cancer Condition

Other Non-cancer Condition:

Pet Gastro-Intestinal Issues

Gastro-Intestinal Issues:

Your Celiac Disease

Celiac Disease:

Child Recurrent Diarrhea

Recurrent Diarrhea:

Child Gastro-Intestinal Issues

Gastro-Intestinal Issues:

Spouse Recurrent Diarrhea

Recurrent Diarrhea:

Spouse Gastro-Intestinal Issues

Gastro-Intestinal Issues:

Pet Recurrent Diarrhea

Recurrent Diarrhea:

How often do you experience recurrent diarrhea?

Spouse Weekly

Weekly

Spouse Monthly

Monthly

Child Monthly

Monthly

Spouse Recurrent Nausea

Recurrent Nausea:

Child Recurrent Nausea

Recurrent Nausea:

Pet Recurrent Nausea

Recurrent Nausea:

Spouse Recurrent Acid Reflex

Recurrent Acid Reflex:

Child Recurrent Acid Reflex

Recurrent Acid Reflex:

Pet Recurrent Acid Reflex

Recurrent Acid Reflex:

Spouse Ulcerative Colitis

Ulcerative Colitis:

Child Irritable Bowel

Irritable Bowel:

Child Ulcerative Colitis

Ulcerative Colitis:

Pet Ulcerative Colitis

Ulcerative Colitis:

Spouse Celiac Disease

Celiac Disease:

Child Celiac Disease

Celiac Disease:

Pet Celiac Disease

Celiac Disease:

Spouse Irritable Bowel

Irritable Bowel:

Pet Irritable Bowel

Irritable Bowel:

Spouse Tumor/Cancer of

Tumor/Cancer of:

Pet Tumor/Cancer of

Tumor/Cancer of:

Pet Esophagus

Esophagus:

Child Tumor/Cancer of

Tumor/Cancer of:

Child Esophagus

Esophagus:

Spouse Esophagus

Esophagus:

Spouse Stomach

Stomach:

Child Stomach

Stomach:

Pet Stomach

Stomach:

Spouse Non-cancer Liver Disease

Non-cancer Liver Disease:

Child Non-cancer Liver Disease

Non-cancer Liver Disease:

Child Liver Cancer

Liver Cancer:

Spouse Liver Cancer

Liver Cancer:

Pet Non-cancer Liver Disease

Non-cancer Liver Disease:

Pet Liver Cancer

Liver Cancer:

Spouse Other Non-cancer Condition

Other Non-cancer Condition:

Child Other Non-cancer Condition

Other Non-cancer Condition:

Pet Other Non-cancer Condition

Other Non-cancer Condition:

Spouse Other Tumor/Cancer

Other Tumor/Cancer:

Pet Other Tumor/Cancer

Other Tumor/Cancer:

Child Other Tumor/Cancer

Other Tumor/Cancer:

Did the health of your Spouse/Partner change in any significant way since they became a Resident of the Community?

Yes No

Spouse Other Tumor/Cancer

Other Tumor/Cancer:

Did the health of your child[ren] change in any significant way since they became a Resident of the Community?

Yes No

Did the health of any of your pets change in any significant way since you became a Resident of the Community?

Yes No

Did the health of any other family member other than your Spouse/Partner or Child[ren] change in any significant way since they became a Resident of the Community?

Yes No

Friend Gastro-Intestinal Issues

Gastro-Intestinal Issues:

How often do you experience recurrent diarrhea?

Friend Monthly

Monthly

Friend Weekly

Weekly

Friend Recurrent Diarrhea

Recurrent Diarrhea:

Friend Recurrent Nausea

Recurrent Nausea:

Friend Recurrent Acid Reflex

Recurrent Acid Reflex:

Friend Ulcerative Colitis

Ulcerative Colitis:

Friend Celiac Disease

Celiac Disease:

Friend Tumor/Cancer of

Tumor/Cancer of:

Friend Irritable Bowel

Irritable Bowel:

Friend Stomach

Stomach:

Friend Esophagus

Esophagus:

Friend Non-cancer Liver Disease

Non-cancer Liver Disease:

Friend Other Non-cancer Condition

Other Non-cancer Condition:

Friend Liver Cancer

Liver Cancer:

Friend Other Tumor/Cancer

Other Tumor/Cancer:

If you answered “Yes,” please indicate regarding the following list of possible health problems, how your health changed since you became a Resident of the Community:

HOFFMAN TENANTS HEALTH QUESTIONNAIRE