Illness Survey
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Relationship to name being reported *
Name of person affected (firstname lastname) *
Maiden Name (if different from name above)
Date of Birth ( mm/dd/yyyy)
Email address where we can contact you (optional)
Phone number (optional)
Current home address (optional)
Address of house/apartment where you or other persons were exposed to unhealthy environment
City (Garland is default)
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State (TX is default)
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Zip Code *
Approximate Year of Diagnosis (yyyy) *
Timeframe you lived at the residency in affected neighborhood (use format 1960-1970) *
Description of Diagnosis (specific as possible) *
Current Status or Condition *
Date of death if applicable (mm/dd/yyyy)
Comments (optional)
I authorize use or disclosure of this information about me (or person affected) *
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