CHILD CANCER SURVEY FORM

Question	Answers should be for the time period only from 3 months before conception to the time of cancer diagnosis
How close was home to currently active agriculture/farming areas - (such as citrus groves, etc)? Please be specific.
If answer is yes to above question, What type of agriculture was patient close to?
If no agriculture areas are currently close to the home, was there ever any agriculture conducted in the past around your home?
If the cancer affects an adult? Did the person ever follow mosquito spray trucks (as children often did on their bicycles) when there was a thick fog plume? If yes, how often.
Was professional pest control used inside the home for roaches, ants, etc. If yes, how often?
Did you or family members ever apply pesticides inside the home yourselves – such as roach sprays etc? If yes, list type of chemical, how often and how applied.
Were lawn pesticides ever applied? If yes, how often and by which company?
Were shrubbery pesticides ever applied? If yes, how often and by which company?
Were termite treatments ever applied while in the home? Explain.
Did the mother consume diet drinks containing aspartame (nutra-sweet) during pregnancy. If yes, how often?
Did father consume diet drinks prior to conception? If yes, how often?
Were flea bombs (aerosol or smoke vapor) ever used in the home? If yes, type and how often?
Were liquid or powder flea treatments ever applied to the interior of the home – these are where the pesticide is usually sprayed over the entire carpet and/or couches?
What type of laundry detergent was used?
Was any fabric softener used? If yes – what type of product - Brand Name – liquid or sheets?
How often was bleach used as a cleaning or disinfecting agent in the home?
How often was pine cleaner used in the home?
Were any fragrance products (such as plug-ins – or aerosols) ever intentionally used to add fragrance to the household air?
Year home was built?
Was home wood or concrete block construction?
Type of flooring – carpet – tile etc? Explain if different for different rooms?
Was new carpet ever installed during the three months before conception up until cancer diagnosis - if yes, when?
Was new paint ever applied? If yes, was latex or oil paint used? Also, if you recall the brand name, please list – Benjamin Moore, Walmart, Glidden etc.
What type of pet was in the home?
How often was the pet treated for fleas with chemical flea treatments?
How often did mother use perfume? What type if known?
How often did father use colognes? What type if known?
Type of deodorant used by the mother? If none, please state
Type of deodorant used by the father?
Type of shampoo used by the mother?
Type of hair creme-rinse used by the mother?
How often was finger nail polish applied by the mother? Was this done in a salon or at home?
How often were hair permanents done?
Did the mother color her hair? If yes, what type and what color?
Did the mother use a face "foundation" base-make up? What type? Creme, powder, etc.
How often was hair spray applied by the mother? What type?
Did the father ever use any type of hair coloring, creme, tonic or hair spray? Explain
Job occupation of mother?
Job occupation of father?
How often and how long did the patient use a pacifier as a child?
List type of x-rays taken of cancer patient prior to cancer diagnosis.
Did mother receive anesthesia during pregnancy (dental, etc.) (not counting during child delivery). Please explain.
What type of anesthesia procedure was used when child was born? local, spinal block, general anesthesia, etc.? Please be as specific as possible
Were you conscious when your child was born?
Was any remodeling done in the home? Painting? Drywall, wall paper, etc. – Please detail
How often were moisturizing skin creams applied over the body? What type?
How often was suntan lotion used by mother? If you know the SPF number please list.
How often was suntan lotion put on child before cancer diagnosis? - List SPF number.
Do you know how close the nearest trash incinerator was to your residence?
Was the flavor enhancer ACCENT' ever used on foods? If yes, how often?
Are you aware of any foods eaten regularly which contained monosodium glutamate (MSG)? These often include flavored potato chips, cheetos type snacks, frozen pizza, soups, etc.
How much did the cancer patient's mother drink alcohol during pregnancy?
How much did the father drink alcohol 3 months prior to conception?
How much did the patient’s mother smoke during pregnancy?
How much did the patient’s father smoke 3 months prior to conception?
If the patient reached school age, was the patient ever enrolled in special education classes - if yes, which type?
Email address for sending cancer survey results

Type of cancer originally diagnosed
Age of individual when cancer was diagnosed
Sex of the person with cancer
Age of mother when child was born
Age of father when child was born