CHILD SURVEY CHIQUITA CANYON LANDFILL LITIGATION If you have minor children, please complete the following survey ONCE for each child. When completed, you will have the opportunity to fill out the survey again. Name of Child * First Name Last Name Name of Parent/Legal Guardian * First Name Last Name Age * Name of School Attending (if any): HEALTH Medical Symptoms (check all that apply) * Headaches Migranes Nausea Vomiting Brainfog Nosebleeds Difficulty Breathing Asthma Cancer Heart problems Thyroid Indigestion Congestion Sinus Pressure/Blockage Eye Itchiness, Swelling, or Dryness Skin Issues (rashes, etc.) Sore or Dry Throat Unexplained Allergic Reactions Insomnia Vertigo or Dizziness Weakness Lethargy or Tiredness Anemia Tumors Loss of Hearing Loss of Vision Loss of Taste or Smell Loss of voice Memory Loss or Poor Memory Hair Loss Liver Damage Joint or Muscle Pain Chest Pain Numbness Ear Infections OTHER (please list below) Other Medical Concerns (not listed) If you answered ‘YES’, did your medical provider believe that your above-mentioned symptoms could be environmentally caused? YES NO Do you feel that your child’s symptoms are: * Getting Worse Staying the Same Getting Better Have you sought medical attention for any of the above-mentioned symptoms * YES NO Do you have a family history of any of the above-mentioned symptoms? * YES (please list below) NO If you answered 'YES' above, please list your family history: Do you (personally) believe that the Landfill has caused these medical-symptoms? * YES NO Are there any other concerns for your child we should be aware of?
